Wednesday, April 15, 2009

Physicians Morphing into Data Entry Clerks

There is something wrong with the general positioning of technology in healthcare especially when you consider it relative to other industries. In no other industry do the most highly paid, skilled knowledgeable workers become data entry clerks. You don't find technology vendors working on optimizing the stock tracking systems to allow the CEO of Merrill Lynch to enter stock data in his financial tracking program.........

So, why oh why in healthcare do we spend enormous amounts of energy finding ways to make doctors more efficient in capturing data and entering that information into electronic medical records systems?

Philips Dowd, a former clinical associate professor of medicine at Brown University and an internist and hematologist suggests that these systems are not ready for prime time. The iHealthBeat site features a review of an opinion piece written by Dr Dowd for the Providence Journal: "Physician Says EHR Systems Turn Doctors Into 'Clerk-Typists" that places EHR's "where cell phones were at in the 1980s: primitive, proprietary and expensive".

Wrapped up in this piece are two major issues:
  • Capturing the data
  • Communicating the data
The capturing of data represents an ongoing challenge and the data hungry EHR's need to be fed. In fact much of the drive towards electronic records is being fanned by insurers who see this as a path to
reduce their billing costs and increase control over denials and prescription services
But as he rightly points out
patients found the [EHR] disrupted what had been a fluid, meaningful dialogue....the system offered little assistance and increased the time required to complete and record a patient visit
The process of interacting with a patient is an integral part of the clinical decision making and diagnostic process. Questions, answer and observation (dramatized to an extreme but not widely removed from reality in the clever series House on TV). Electronic systems have yet to facilitate this process and disrupt was has been meaningful and important element of patient clinical interaction. Dowd's summary brings this point home:
I see the [EHR] as the final stage in the forced metamorphism of physicians from thoughtful professionals to clerk-typists from the Katherine Gibbs School of Medicine
This is true and I heard in a recent discussion with a physician that his clinical interaction and the questions he asks has been changed as a result of the implementation of a structured EHR and data entry systems. With experience using the system he discovered that anything that was not covered in the "standard" replies available in the system cost him much more time......inevitably in a time pressured world he found himself not asking questions fearing a non-standard response from his patient and requiring a complex and time consuming additional data entry. The change from the widely used open ended questions to closed simple yes/no interactions is not likely to elicit more information or add greater value to the diagnostic clinical history taking.

Facilitating this data entry and voice enabling the capture of structured meaningful clinical documents cannot come fast enough. Technology can and already does automate some of this using Speech Understanding which understands words and their underlying context and meaning and output structured and meaningful clinical documents in Clinical Document architecture (CDA) format - or put another way The Full Healthstory that encompasses both the detailed narrative alongside the structured and encoded clinically actionable data necessary to drive the EHR and decision support systems. In addition the delivery of these structured documents are already available from many of the medical transcription service organizations (MTSO) who capture and produce CDA Healthstory documents. The Medical Transcriptionist is the knowledge based worker here to support and enable the clinicians to capture the information quickly, accurately and effectively. Right now many customers elect to receive text or word output but the rich meta data is available and health systems, doctors offices and physician practices should be asking for the Full Healthstory form their MTSO provider.

The challenge of communicating the data Dr Dowd rightly pointed out what every patient knows through the nauseam of multiple form filling activity in clinical offices
My brand can't speak to your brand or group or hospital
There is no sharing of data and information is repeated, recaptured and fails to be shared effectively between clinical teams. Walk into any clinical office and the first thing they do is ask you to fill in YAPF (Yet Another Paper Form) that contains much of the data you know is in multiple systems around the various clinical offices they have visited (an average Heart Failure patient visits 23 different providers per year). You can bet they fill out 23 or more different forms!

Once again the CDA concept allows for easy adoption and sharing of the full Healthstory. The standard encompasses all the elements necessary for good patient care, administration, reporting and research and importantly includes the narrative. You can download the Healthstory Q1 business update here (warning ppt download) and you can find out more about joining here. Everyone, patients, clinicians, hospitals, insurers and healthcare facilities should all be insisting on the full Healthstory

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