I Can't See My Patients Because I'm At A Screen Entering Data

As with so many services the world is getting flatter (per Thomas Friedman: The World is Flat - A Brief History of the Twenty-first Century) and medical services and in particular medical care is no exception. Everyone must run faster just to stay in place even the health care profession. We are seeing increasing interest and uptake of "Medical Tourism" (this term seems wrong to me - it reminds me of "Friendly Fire") and a recent posting on the Wharton Site on Health Economics: Bangkok's Bumrungrad Hospital: Expanding the Footprint of Offshore Health Care (Props to HISTalk). As with many of the offshore medical facility there are questions regarding safety and oversight (see this web site regarding Jim Goldberg's 23 year old son who died there and he is convinced there is a cover up and conspiracy).

That aside the interview with Mack Banner CEO of Bumrungrad makes for interesting reading especially when it comes to the implementation of their Electronic Medical Record system (in this case Microsoft's Amalga) and their move towards a totally digital hospital. This is interesting not least of all because Microsoft is exploring this vertical in another country and developing a solution that we will likely see being rolled out in this country once they have worked out all the issues and filled in feature/functionality gaps. But from a documentation standpoint as Kenneth Mays (the Hospital's Director of Marketing) points out:

We talk to our colleagues in the States and they're all facing the same challenge of getting doctors to enter things into computers. It's wonderful in theory. It makes your system more efficient. It makes it faster. It takes out a big source of errors. But it requires doctors to type in these things and it's not easy to get doctors to do that. It could also take something away from the doctor-patient interaction if the doctor has his head buried in a computer rather than looking at the patient and having a dialogue with the patient.... Hospitals, not just our hospital but I think hospitals everywhere, are facing this challenge.

This challenge is significant and one that remains unanswered in the limited roll out of EMR's. In fact a recent Washington Post article: "Electronic medical Records not seen as a cure-all" Alexi Msotrous makes the point that while everyone appears to agree that American Medicine needs to go digital (it is probably broader than that and I would suggest worldwide medicine needs to go Digital) the results are less than stellar and in some cases

suggest that computer systems can increase errors, add hours to doctors' workloads and compromise patient care

Yikes! The Senate Finance Committee has sent a letter to 10 major vendors demanding to know what steps have been taken to safe guard patient data - I expect the responses will be made public which should make for interesting reading. Meanwhile David Bluementhal rightly points out that

the critical question is whether, on balance, care is better than before and he (David Blumenthal) said. "I think the answer is yes"

I agree - we cannot continue the paper based record and we need data to feed these systems to make them useful. But to get this data in creates a data entry challenge that one physician said

I can't see my patients because I'm at a screen entering data

AND

his department found that physicians spent nearly five of every 10 hours on a computer, he said. "I sit down and log on to a computer 60 times every shift. Physician productivity and satisfaction have fallen off a cliff"

And my own daughter (as a patient) from her experience interacting with a physician office said "I wish the doctor would look at me as much as she looked at her computer" (See Doctor Please Look at Me not Your EMR).

The answer lies in using the current methodologies for capturing information - dictation, forms, and other tools that are blended to provide the easiest and most facile way to capture the data for clinicians. Making the data capture part of the clinical interaction without taking it over is essential. Clinicians talk faster than they can type - capturing that information and making this narrative tagged with semantically interoperable data that is usable by the EMR is possible today. Technology, standards and resources exist that allow for this today.

What would you rather be doing - typing at a screen or talking to your patients?

Cause and Effect - Unintended Consequences

It was the story of the story of the Indiana Grandmother of Triplets whose picture ended up on the front page of her local newspaper titled "Drug Sweep" for the crime of buying two boxes Cold medication that got me thinking about the effect each of us has and fail to realize. She was arrested and prosecuted by the local Prosecutor (Nina Alexander) :

The public has the responsibility to know what is legal and what is not, and ignorance of the law is no excuse

whose inability to see past rules and regulations and direct transference of the problem directly to "the customer". As James Shott writes in Observations in his piece "Citizens deserve service from Lawmakers" the prosecutor clearly lost site of who precisely she was serving:

But does the public not also have a reasonable expectation that laws will be rational and bureaucrats will use common sense?

It would appear not in this case nor in this case. Working the other way was the surprise to the prison authorities in the United Kingdom who introduced anti bacterial hand gel pumps but quickly withdrew them when they discovered inmates were drinking the gel: "HM Prisons ban Anti Bacterial Hand Gel" - interesting they also mention the Royal Bournemouth Hospital was having the same problem and said:

it was one of many hospitals removing alcohol-based hand cleaning gel from reception areas in a bid to stop visitors drinking it

Who would have thought it!

But the same is true with money focused on healthcare reform already approved which according to Mark Leavitt from CCHIT and his presentation at AHIMA last week amounts to $36 Billion. As Kelly Mclendon from HIXPerts pointed out in his presentation this proposals are no longer proposals and the regulation went into effect September 23, 2009 (enforcement may be delayed but it's coming) with a series of focus areas:

• Incentives Meaningful Use and Certified EHR's
• Workforce Expansion
• HIPAA - Privacy and Security
• Data Exchange
• Regional Centers (CER)

As quoted in the presentation - the Office of the National Coordinator (ONC) said on Meaningful use:

To some providers, particularly small or already stretched physician practices or small, rural hospitals, the path toward meaningful use may still seem arduous. To others, who would just prefer to stick with the "status quo," it may seem like an unwanted intrusion. We believe that the time has come for coordinated action. The price of inaction – in adverse events, lost patient lives, delayed or improper treatments, unnecessary procedures, excessive costs, and so on – is just too high, and will only get worse

This train has left and if you are left in any doubt as to the likelihood of the digitization of medicine is coming - ready or not. In the current documents for certification published on the CCHIT web site (warning pdf: Comprehensive Certification Handbook) a quick search of the for the following terms revealed the following number of hits:

Transcription - 0
Dictation - 0
Narrative - 1 ("Textual narratives must be present in each required section")

And the same in the Document (warning pdf: Meaningful Use Matrix Tagged for CCHIT Reference):

Transcription - 0
Dictation - 0
Narrative - 0

While this is neither scientific or conclusive it does represents the potential for unintended consequences. I wonder how many physicians can imagine their lives without Dictation, Transcription and Narrative. There are studies questioning the effects of technology on healthcare with the widespread implementation. Unfortunately subscription required for full articles - Journal of Biomedical Informatics: Qualitative studies to Improve Usability of EMR) - interference with worklfow as one of the posible challenges. More data continues to emerge that suggests that even for the oft cited "young" physician who grew up in an era awash with technology, computers keyboards still fail to transition easily to documentation using a keyboard and mouse once they enter a busy clinical practice overwhelmed with patients. As the Healthstory consortium states:

Approximately 1.2 billion clinical documents are produced in the United States each year. Dictated and transcribed documents make up around 60% of all clinical notes

With the looming regulations and incentives that currently take very little account of this enormous block of data. In fact in many instances have been promoting how they plan or propose to get rid of it, ostensibly to "save money" offers an opportunity to watch untended consequences grind the system to a halt. Anecdotal stories of physicians who are forced to spend more time on documentation for the purposes of clinical systems and in the case of the NPR story today: How the Modern Patient Drives up Health Costs that featured a tearful Dr Teresa Moore whose Keysville practice is overwhelmed with paperwork that finds her

stay(ing) at her office late into the night, trying to complete paperwork so that she is able to spend enough time with her patients during the day — enough time to explain why this test is probably not necessary, why that pill wouldn't be a good idea. And her children, she says, pay the price

In this story the focus is the additional burden of the educated patient questioning care, asking for alternatives or bringing in internet print outs and adverts. But the principles and issues remain the same - and as she says when asked if she preferred the old passive patient or the newer more demanding modern patient

But I do like an educated patient who's willing to read about their health issues. So I guess I'd like someone in the middle

Having others deal with the burdens of documentation (or in this case insurance that in her words: "Sometimes you have to request a form just to get the correct form — you do. You have to fill out a form stating the preauthorization form that you need") would help alleviate the strains placed on the clinical providers. But without involvement and participation of the providers of clinical documentation services we may be caught up in unintended consequences both from the perspective of the patient but also from an industry.

Be part of the solution and get involved - join Healthstory, get involved in Advocacy and provide input to the Rule Making and definition of Meaningful use.

Doctor Please Look at Me not Your EMR

A recent personal experience with a pediatric office that I have been attending with my children for the last 7 years provides some valuable insight into the effect of an electronic medical record on a typical busy general pediatric clinical practice.

A little history - this practice has been servicing patients in our area for many years. Currently there are 7 physicians on staff and they have regular hours and see patients 6 out of 7 days providing on call coverage at all other times. They are great, my kids like them and my wife and I both love the practice. I have been to the practice and watched the impact of the implementation of an Electronic Medical Record (EMR) over the last 18 months. I was there shortly after they went live with their new system and watched as the clinicians struggled with a large unwieldy tablet using a combination of tablet and keyboard entry that clearly was uncomfortable and difficult for a physician who in previous visit had been highly efficient with a pen and paper based record.

The most recent visit was simple physical examination immunization and paper work for participation in sports programs. What should have been a brief efficient visit was not but it was my 10 year old who pretty much summed up the experience

She (the doctor) spent more time looking at her computer than at me

Practical medicine is about body language, facial expressions and interpreting more than just what someone says. The picture below dates back some years to an implementation of an EMR I was involved with in 1993 - the patient in the bed is ignored by the 5 doctors focused on the EMR screen in the corner:

When you ask a patient if there anything else that's bothering them you don't just listen to the answer but look at their face and the way they behave. There are clear indication if this patient is going to drop some significant additional piece of information on you with the classical line, often delivered as the patient is standing up and reaching for the door know

Oh and by the way doc..."insert interesting/relevant piece of clinical data"....thought that might be relevant"

It's a well known phenomena - part of our general make up that prevents from arriving at the doctors office for a "routine visit" and when first asked if you have any problems opening with

Yes, I have been bleeding rectally for the last 3 days, it's fresh blood

We all dread sharing what in our heart of hearts we know is bad news even though most know that early detection, treatment and dealing with problems is a much better strategy than putting our head in the sand:



To be clear I am not leveling criticism at our physicians - they are doing the best with the hand they have been dealt. Their perception of the EMR has changed over the course of this implementation. Prior to the implementation (which predates the economic crisis and the current rush towards a set of incentives currently linked, albeit with poor clarity, to implementing an EMR) they were not excited by the prospect of imposition of technology. Their decision was driven by their lead physicians drive towards modernization and the belief that current paper based systems were failing them in delivering the best possible care. They reviewed the choices and selected based on their needs. During the implementation the sentiment was very clear - everyone was fed up with the additional overhead required to cope with the new system and the huge change required in their day to day work flow and clinical practice.

Now many months on things have settled down. In the words of one of their physicians - they love the ready access to all the information on their patients when they are seeing them. For the most part the presentation of patient data is helpful and easily navigated..........but the capturing of this information is a burden and interferes with the clinicians/patient relationship.

Clinicians need to look at their patients, they need to interact with their patients and technology should not interfere with this essential component of the diagnostic process. Computers can be part of that interaction but currently in the vast majority of implementations they are a distraction and interfere. As my 10 year old said

Why is the doctor more interested in her PC than in me?

In fact in a recent exchange the story is even more disturbing with the roll out of these EMR's. A clinicians recently shared with me that his clinical interaction had changed since the new EMR system had been implemented. Since the system presented him with a series of choices to questions he would ask questions designed to elicit responses that were featured in the list. If he thought a question might elicit a response that was not featured in the list of choices available he would avoid that question since documenting the response was a time costly exercise.

Dictation has long been tainted as a problem not a solution....but dictation has been the mainstay of capturing clinical information. We moved from hand written notes to dictation and transcription as the volume of information increased. It made sense because off loading the heavy lifting of creating a typed legible note was more efficiently done by someone who specialized in that process and was more cost effective than asking a clinicians to spend more time documenting and less time seeing patients.

Despite the bad rap dictation and transcription is the mainstay of clinical information today - 60% of the data we have on patients is generated by dictation and transcription. Of the remaining 40% the vast majority of this data comes from automated clinical systems including laboratory and imaging systems that generate data - not clinicians who currently generate somewhere in the region of 3-5% of this information input into EMR's today.

But to satisfy the informational needs of the EMR we need the clinical data. This is possible today and the technology is available to make the process of dictation and transcription not only more efficient and cost effective but generating the data necessary to fill the information void in the EMR's. Instead of just accepting the concept that physicians should become data entry clerks ask how you can use existing technology and services to allow doctors to focus on their patients not on an inanimate piece of technology

I'll leave it to my 10 year old to sum it up

I wish she (the doctor) would look at me not her computer

How have your experiences been in any recent visits to your doctors office. Do they have clinical systems and do they interfere with your relationship with your doctor(s)? Let me know - I'll publish any stories people are willing to share