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Preventive health: Getting rid of the middleman (uh-oh, that’s us!)
As physicians, we find that preventive health is, frankly, really difficult. It requires thinking about a changing list of recommendations unprompted by the symptoms for which patients present. Compounding that challenge is that, in doing preventive health well, we need to have personalized discussions with our patients and this requires they come into the office, which doesn’t always happen on a regular basis. Furthermore, when patients do come in, they usually are presenting for an acute care visit, so there is little time set aside to discuss preventive health.
For all these reasons and many others, the data suggest that we are not particularly good at performing preventive health maintenance. We are much better at figuring out diagnostic dilemmas and choosing among competing medications or procedures to most effectively address acute and chronic medical problems. Let’s examine the data to see if there is a shred of truth in what we are saying; then let’s look at a potential solution to the dilemma of preventive health that we all believe in and that we carry out less frequently than any of us would like.
First, let’s look at recent data on cancer screening reported by the CDC1:
- Mammography: 72% of women aged 50–74 years reported having had a mammogram within the past 2 years.
- Pap test: 83% of women reported being up to date with cervical cancer screening.
- Colorectal cancer screening: 62% of men and women reported colorectal cancer screening test use consistent with USPSTF recommendations.
Of note, colorectal cancer screening has improved dramatically over he last 15 years, while screening for breast and cervical cancer has largely plateaued.1
Our success with cancer screening – or lack thereof depending upon one’s perspective – looks quite good next to national vaccination rates for adults. The immunization rate for commonly recommended vaccines are as follows2:
- The Tdap vaccination rate is 20%.
- The tetanus-diphtheria vaccination rate is 62%.
- The herpes zoster vaccination rate is 28%.
- The influenza vaccination rate is 43%.
- The pneumococcal vaccination rate among high-risk persons aged 19-64 years is 20% and among adults aged greater than or equal to 65 years is 61%.
Of adults who had health insurance and at least 10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended.
In the business literature there is a great deal of disagreement about the value of the “middleman.” The term middleman describes someone who brings the product from the producer, or factory, to the consumer. On the one hand, if the factory can sell the product directly to the consumer, the consumer can save money and the factory can make more money. On the other hand, if the middleman can help the consumer make a better choice among the variety of products available, then the middleman provides value and the consumer benefits.3
Traditionally, clinicians have served the role of the middleman for preventive health activities, knowing what to recommend to patients and informing them of the correct preventive health choices that fit their needs. The problem with this concept is that preventive health recommendations are largely demographically based, are tied to population-based risk assessment, and usually require very little individual judgment.
We as physicians are good at – and I believe truly enjoy – exercising judgment. We love thinking things through and helping the person in front of us. We are not as good at remembering unprompted information in the middle of busy visits that are often made for unrelated reasons. Most of the people who have not had a colonoscopy or pneumococcal vaccine have not decided against the procedure after a detailed discussion with their physician. On the contrary, the service was never recommended, or it was recommended, but the patient did not follow up to have the procedure performed.
Let’s now imagine another approach. You’re a patient and once a year you click on an email that shows up in your inbox from your doctor with the words “Preventive Health” in the subject line. The EHR – based on your gender, age, and a query of what has been documented in your chart – has determined the preventive health activities that are recommended for you. You can choose to pursue, opt out, or get more information for each of the recommended preventive services as you read through them.
If you choose to have more information, it is provided in a structured format that allows you to drill down to the level of detail that you desire. In all probability, you will find a greater level of detail and accuracy of information about each preventive service than could possibly be provided during a routine office visit. Specifics about the risks and benefits of the procedure will also be more extensive, as it is unlikely your care providers are able to keep all of the details and risk ratios in their heads. If desired, you as a patient can take your time to read and digest the information, sleep on it, and come back to it to make an informed decision. This is not something you can do during a routine office visit.
If you choose to opt out of the procedure, just click the “declined” box. Otherwise, when you’ve made all of your decisions and indicate that you’re done, the necessary prescriptions for blood work and x-rays, as well as referrals to the appropriate specialists, will print out. An entry will also be made in the electronic record showing you’ve been provided preventive health recommendations that are appropriate for your age and sex and made your preferred choices. At any point, if you feel you’d like further discussion with your physician, you can make an appointment electronically through the interface.
The hurdles for implementing such a system are real, but they are solvable, and the development of such an approach is inevitable, enviable, and will ultimately be good for both patients and their providers. Patients will get more predictable and complete recommendations for preventive care and providers will have more time to do what we enjoy and are most skilled at – talking with patients to clarify diagnoses, decide upon treatment, and clarify questions that come up about preventive health recommendations.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. White A et al. Cancer screening test use – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 3;66(8):201-6.
2. Williams WW et al. Surveillance of vaccination coverage among adult populations – United States, 2014. MMWR Surveill Summ. 2016 Feb 5;65(1):1-36.
3. Conerly B. Don’t eliminate the middleman – He’s much too valuable. Forbes. Oct 28, 2015.
As physicians, we find that preventive health is, frankly, really difficult. It requires thinking about a changing list of recommendations unprompted by the symptoms for which patients present. Compounding that challenge is that, in doing preventive health well, we need to have personalized discussions with our patients and this requires they come into the office, which doesn’t always happen on a regular basis. Furthermore, when patients do come in, they usually are presenting for an acute care visit, so there is little time set aside to discuss preventive health.
For all these reasons and many others, the data suggest that we are not particularly good at performing preventive health maintenance. We are much better at figuring out diagnostic dilemmas and choosing among competing medications or procedures to most effectively address acute and chronic medical problems. Let’s examine the data to see if there is a shred of truth in what we are saying; then let’s look at a potential solution to the dilemma of preventive health that we all believe in and that we carry out less frequently than any of us would like.
First, let’s look at recent data on cancer screening reported by the CDC1:
- Mammography: 72% of women aged 50–74 years reported having had a mammogram within the past 2 years.
- Pap test: 83% of women reported being up to date with cervical cancer screening.
- Colorectal cancer screening: 62% of men and women reported colorectal cancer screening test use consistent with USPSTF recommendations.
Of note, colorectal cancer screening has improved dramatically over he last 15 years, while screening for breast and cervical cancer has largely plateaued.1
Our success with cancer screening – or lack thereof depending upon one’s perspective – looks quite good next to national vaccination rates for adults. The immunization rate for commonly recommended vaccines are as follows2:
- The Tdap vaccination rate is 20%.
- The tetanus-diphtheria vaccination rate is 62%.
- The herpes zoster vaccination rate is 28%.
- The influenza vaccination rate is 43%.
- The pneumococcal vaccination rate among high-risk persons aged 19-64 years is 20% and among adults aged greater than or equal to 65 years is 61%.
Of adults who had health insurance and at least 10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended.
In the business literature there is a great deal of disagreement about the value of the “middleman.” The term middleman describes someone who brings the product from the producer, or factory, to the consumer. On the one hand, if the factory can sell the product directly to the consumer, the consumer can save money and the factory can make more money. On the other hand, if the middleman can help the consumer make a better choice among the variety of products available, then the middleman provides value and the consumer benefits.3
Traditionally, clinicians have served the role of the middleman for preventive health activities, knowing what to recommend to patients and informing them of the correct preventive health choices that fit their needs. The problem with this concept is that preventive health recommendations are largely demographically based, are tied to population-based risk assessment, and usually require very little individual judgment.
We as physicians are good at – and I believe truly enjoy – exercising judgment. We love thinking things through and helping the person in front of us. We are not as good at remembering unprompted information in the middle of busy visits that are often made for unrelated reasons. Most of the people who have not had a colonoscopy or pneumococcal vaccine have not decided against the procedure after a detailed discussion with their physician. On the contrary, the service was never recommended, or it was recommended, but the patient did not follow up to have the procedure performed.
Let’s now imagine another approach. You’re a patient and once a year you click on an email that shows up in your inbox from your doctor with the words “Preventive Health” in the subject line. The EHR – based on your gender, age, and a query of what has been documented in your chart – has determined the preventive health activities that are recommended for you. You can choose to pursue, opt out, or get more information for each of the recommended preventive services as you read through them.
If you choose to have more information, it is provided in a structured format that allows you to drill down to the level of detail that you desire. In all probability, you will find a greater level of detail and accuracy of information about each preventive service than could possibly be provided during a routine office visit. Specifics about the risks and benefits of the procedure will also be more extensive, as it is unlikely your care providers are able to keep all of the details and risk ratios in their heads. If desired, you as a patient can take your time to read and digest the information, sleep on it, and come back to it to make an informed decision. This is not something you can do during a routine office visit.
If you choose to opt out of the procedure, just click the “declined” box. Otherwise, when you’ve made all of your decisions and indicate that you’re done, the necessary prescriptions for blood work and x-rays, as well as referrals to the appropriate specialists, will print out. An entry will also be made in the electronic record showing you’ve been provided preventive health recommendations that are appropriate for your age and sex and made your preferred choices. At any point, if you feel you’d like further discussion with your physician, you can make an appointment electronically through the interface.
The hurdles for implementing such a system are real, but they are solvable, and the development of such an approach is inevitable, enviable, and will ultimately be good for both patients and their providers. Patients will get more predictable and complete recommendations for preventive care and providers will have more time to do what we enjoy and are most skilled at – talking with patients to clarify diagnoses, decide upon treatment, and clarify questions that come up about preventive health recommendations.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. White A et al. Cancer screening test use – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 3;66(8):201-6.
2. Williams WW et al. Surveillance of vaccination coverage among adult populations – United States, 2014. MMWR Surveill Summ. 2016 Feb 5;65(1):1-36.
3. Conerly B. Don’t eliminate the middleman – He’s much too valuable. Forbes. Oct 28, 2015.
As physicians, we find that preventive health is, frankly, really difficult. It requires thinking about a changing list of recommendations unprompted by the symptoms for which patients present. Compounding that challenge is that, in doing preventive health well, we need to have personalized discussions with our patients and this requires they come into the office, which doesn’t always happen on a regular basis. Furthermore, when patients do come in, they usually are presenting for an acute care visit, so there is little time set aside to discuss preventive health.
For all these reasons and many others, the data suggest that we are not particularly good at performing preventive health maintenance. We are much better at figuring out diagnostic dilemmas and choosing among competing medications or procedures to most effectively address acute and chronic medical problems. Let’s examine the data to see if there is a shred of truth in what we are saying; then let’s look at a potential solution to the dilemma of preventive health that we all believe in and that we carry out less frequently than any of us would like.
First, let’s look at recent data on cancer screening reported by the CDC1:
- Mammography: 72% of women aged 50–74 years reported having had a mammogram within the past 2 years.
- Pap test: 83% of women reported being up to date with cervical cancer screening.
- Colorectal cancer screening: 62% of men and women reported colorectal cancer screening test use consistent with USPSTF recommendations.
Of note, colorectal cancer screening has improved dramatically over he last 15 years, while screening for breast and cervical cancer has largely plateaued.1
Our success with cancer screening – or lack thereof depending upon one’s perspective – looks quite good next to national vaccination rates for adults. The immunization rate for commonly recommended vaccines are as follows2:
- The Tdap vaccination rate is 20%.
- The tetanus-diphtheria vaccination rate is 62%.
- The herpes zoster vaccination rate is 28%.
- The influenza vaccination rate is 43%.
- The pneumococcal vaccination rate among high-risk persons aged 19-64 years is 20% and among adults aged greater than or equal to 65 years is 61%.
Of adults who had health insurance and at least 10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended.
In the business literature there is a great deal of disagreement about the value of the “middleman.” The term middleman describes someone who brings the product from the producer, or factory, to the consumer. On the one hand, if the factory can sell the product directly to the consumer, the consumer can save money and the factory can make more money. On the other hand, if the middleman can help the consumer make a better choice among the variety of products available, then the middleman provides value and the consumer benefits.3
Traditionally, clinicians have served the role of the middleman for preventive health activities, knowing what to recommend to patients and informing them of the correct preventive health choices that fit their needs. The problem with this concept is that preventive health recommendations are largely demographically based, are tied to population-based risk assessment, and usually require very little individual judgment.
We as physicians are good at – and I believe truly enjoy – exercising judgment. We love thinking things through and helping the person in front of us. We are not as good at remembering unprompted information in the middle of busy visits that are often made for unrelated reasons. Most of the people who have not had a colonoscopy or pneumococcal vaccine have not decided against the procedure after a detailed discussion with their physician. On the contrary, the service was never recommended, or it was recommended, but the patient did not follow up to have the procedure performed.
Let’s now imagine another approach. You’re a patient and once a year you click on an email that shows up in your inbox from your doctor with the words “Preventive Health” in the subject line. The EHR – based on your gender, age, and a query of what has been documented in your chart – has determined the preventive health activities that are recommended for you. You can choose to pursue, opt out, or get more information for each of the recommended preventive services as you read through them.
If you choose to have more information, it is provided in a structured format that allows you to drill down to the level of detail that you desire. In all probability, you will find a greater level of detail and accuracy of information about each preventive service than could possibly be provided during a routine office visit. Specifics about the risks and benefits of the procedure will also be more extensive, as it is unlikely your care providers are able to keep all of the details and risk ratios in their heads. If desired, you as a patient can take your time to read and digest the information, sleep on it, and come back to it to make an informed decision. This is not something you can do during a routine office visit.
If you choose to opt out of the procedure, just click the “declined” box. Otherwise, when you’ve made all of your decisions and indicate that you’re done, the necessary prescriptions for blood work and x-rays, as well as referrals to the appropriate specialists, will print out. An entry will also be made in the electronic record showing you’ve been provided preventive health recommendations that are appropriate for your age and sex and made your preferred choices. At any point, if you feel you’d like further discussion with your physician, you can make an appointment electronically through the interface.
The hurdles for implementing such a system are real, but they are solvable, and the development of such an approach is inevitable, enviable, and will ultimately be good for both patients and their providers. Patients will get more predictable and complete recommendations for preventive care and providers will have more time to do what we enjoy and are most skilled at – talking with patients to clarify diagnoses, decide upon treatment, and clarify questions that come up about preventive health recommendations.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. White A et al. Cancer screening test use – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 3;66(8):201-6.
2. Williams WW et al. Surveillance of vaccination coverage among adult populations – United States, 2014. MMWR Surveill Summ. 2016 Feb 5;65(1):1-36.
3. Conerly B. Don’t eliminate the middleman – He’s much too valuable. Forbes. Oct 28, 2015.
“I’m sorry, doctor, I’m afraid I can’t do that”
In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.
Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.
A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.
While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.
Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology1 investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.
There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
Reference
1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.
Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.
A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.
While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.
Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology1 investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.
There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
Reference
1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
In “2001: A Space Odyssey,” the epic 1968 film by Stanley Kubrick and Arthur C. Clarke, humanity makes first contact with an alien intelligence, and the course of history is irreversibly altered. Hailed as a watershed moment in science fiction, “2001” was considered way ahead of its time and raised a number of philosophical questions about what would happen if we ever encountered another form of life. Interestingly, the most noteworthy character in the film isn’t human or alien, but instead a new form of life altogether: an artificial intelligence (AI) known as the Heuristically programmed ALgorithmic computer 9000. HAL (as he is known colloquially) operates the Discovery One spacecraft, ferrying several scientists bound for Jupiter on a mission of exploration. Stating that he is “foolproof and incapable of error,” HAL’s superiority complex leads him to become the film’s antagonist, as he believes that human error is the cause of the difficulties they encounter. He eventually concludes that the best way to complete the mission is to eliminate human interference. When asked by scientist Dr. David Bowman to perform a simple function essential to the survival of the crew, HAL simply states “I’m sorry, Dave, I’m afraid I can’t do that.” Bowman is forced to disconnect HAL’s higher intellectual capabilities, reverting the computer to its most basic functions to ensure human survival.
Kubrick and Clarke may have been overly ambitious in predicting the progress of human space flight, but their call for concern over the risks of artificial intelligence seems quite prescient. Recently, billionaire entrepreneur Elon Musk (CEO of Tesla Motors and SpaceX) raised his concerns about AI, warning that, left unchecked, AI could be mankind’s final invention – one that could eventually destroy us. Other giants of the tech industry, including Bill Gates and Mark Zuckerberg, disagree. They believe AI represents tremendous promise for humanity and could usher in innovations unlike any we have ever seen.
A few weeks ago, we attended a national electronic health records conference where a well-known EHR vendor unveiled the new features in the upcoming release of their software. One of the most noteworthy additions was an intelligent virtual assistant, designed to help providers care for patients. While this is not the first time AI has ventured into health care (see IBM’s “Watson”), it is the first time the idea has become mainstream and fully integrated into physician workflow. Much like the virtual assistants mentioned above, this one can use voice or mouse/keyboard interaction to find clinical information, simplify common tasks, and help with medical decision-making.
While exciting at first, the idea of artificially intelligent EHRs may sound terrifying to some who aren’t yet ready to trust any patient care to machines. Reassuringly, while the integrated virtual assistant mentioned above can make suggestions to guide physicians to the right data or offer decision support when available, it is primarily focused on interface enhancement to improve work flow. It is not yet capable of making true clinical decisions that remove the physician from care delivery, but computers that do the diagnostic work of physicians may be closer than you think.
Research done at Jefferson University in Philadelphia and published in the August 2017 edition of Radiology1 investigated the ability of deep-learning algorithms to interpret chest radiographs for the diagnosis of tuberculosis. The computers achieved an impressive reliability of 99%. While at first radiograph interpretation seems quite different than the diagnostic decision-making done in primary care, the fundamental skill required for both is similar: pattern recognition. To build those patterns, artificial intelligence requires an enormous number of data points, but that’s hardly a problem thanks to the continual collection of patient data through electronic health records. The amount of raw information available to these algorithms is growing exponentially by the day, and with time their predictive ability will be unmatched. So where will that leave us, the physicians, entrusted for generations with the responsibility of diagnosis? Possibly more satisfied than we are today.
There was a time – not long ago – when the body of available medical knowledge was incredibly limited. Diagnostic testing was primitive and often inaccurate, and the treatment provided by physicians was focused on supporting, communicating, and genuinely caring for patients and their families. In the past 50 years, medical knowledge has exploded, and diagnostic testing has become incredibly advanced. Sadly, at the same time physicians have begun to feel more like clerical workers: entering data, writing prescriptions, and filling out forms. As artificial intelligence assumes some of this busywork and takes much of the guesswork out of diagnosis, physicians may find greater job satisfaction as they provide the skills a computer never can: a human touch, a personal and reflective interpretation of a patient’s diagnosis, and a true emotional connection. Ask this of a computer, and the response will always be the same: “I’m sorry, doctor, I’m afraid I can’t do that.”
Reference
1. Lakhani, Paras & Sundaram, Baskaran, “Deep Learning at Chest Radiography: Automated Classification of Pulmonary Tuberculosis by Using Convolutional Neural Networks,” Radiology. 2017 Aug;284:574-82.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
The Inflection Point
In the early 1600s, the French playwright Molière wrote one of the great satires of all time, “The Doctor in Spite of Himself.” In that play the main character, Sganarelle, is a woodcutter who wastes all his money on alcohol, so his wife Martine decides she will teach him a lesson. As she is plotting her revenge, Martine overhears two peasants discussing how they have been trying to find a doctor for their rich employer’s daughter, who has become suddenly mute. Martine seizes the opportunity to tell the peasants that her husband is a brilliant – though eccentric – doctor who usually hides his identity. Learning this, the peasants find Sganarelle and beg him to see their master’s daughter. Though he initially refuses, they berate him until he can take it no more, and he finally says that he is a doctor and agrees to assess the ill young woman.
Sganarelle does his best to impersonate a doctor while examining the young woman, and as he is doing so it becomes apparent even to him that she is not truly ill. She is pretending to be mute because she’s being forced to marry a wealthy man she does not love. Sganarelle discusses the diagnosis with her father, stating, “this impediment to the action of the tongue is caused by certain humors.” He goes on to say that her muteness was triggered by, “the vapors that pass from the left side, where the liver resides, to the right side, where the heart dwells.” The rich aristocrat listens intently and accepts the diagnosis, though he seems puzzled about one thing. “Isn’t the heart on the left side of the chest?” he asks. To this insightful and obvious question Sganarelle replies, “Yes, that used to be true; but we’ve changed all that, and we practice medicine now according to a whole new method.”
It is astonishing that Molière, in a farcical comedy written in the 1600s, could have anticipated the dizzying rate of change in modern medicine. While the heart and liver have not changed sides, the ways we are practicing medicine have undergone landmark shifts over the past 10 years. Just look at the new ways in which we record documentation, learn new information, send in prescriptions, manage populations in addition to individual patients, and so many other aspects of care. At times this evolution has its own satirical feel to it. For example, the notion that refusing to refill an opioid prescription for a patient that broke their opioid contract could lead to a bad review on Yelp or points off on a Press Ganey satisfaction survey does not seem reasonable, but it is real.
When we started this column about 10 years ago, we regularly received emails (and even letters written in fine penmanship and mailed in envelopes) from physicians who felt that the EHR was ruining their practice and their lives. Many of the letters talked about early retirement. Some physicians ended up retiring early. Many of these physicians were smart, able people who we believe took great care of patients. But as Leon C. Megginson, interpreting the work of Darwin, observed, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” Adaptability favors the young; the young have fewer habits to break, few preconceived ideas of how things should be, and perhaps more energy to give to new tasks.
We believe we have now reached the inflection point – a time in the history of an industry where an event (in this case the advent of the EHR) so fundamentally impacts the industry that the industry is changed from that point forward. The industry, and more importantly those who work in the industry, must adopt new approaches and attitudes in order to survive in the changed environment. Andrew Grove, the former CEO of Intel, talked about Strategic Inflection Points in a keynote address to the Academy of Management: “…what is common to [inflection points] and what is key is that they require a fundamental change in business strategy.” Grove also said, “That change can mean an opportunity to rise to new heights. But it may just as likely signal the beginning of the end.”
Up until recently, the introduction of the EHR lead to discussions about what was good and what was bad about the advent of EHRs. That time is past. We no longer receive letters from physicians expressing their concerns about the EHR, as many of those physicians have taken the change as a signal of the end of their careers, and chosen to retire. The rest have adapted to a new world. And in this new world we are certainly rising to new heights. We are forward-focused and looking at the multi-fold ways that our new technologies can accomplish their many missions – to improve the health of the population, to serve as a source of data to assess the real-world effectiveness of novel therapies, to evaluate and affect the quality of care given by practices and individual physicians, and to take excellent personalized care of individual patients. While we are physicians, not wood cutters as in Molière’s play, it remains incumbent upon us never to stop listening to our patients’ hearts, and to interpret their symptoms and signs with common sense, empathy and even humor when appropriate, all the while embracing approaches that move the health care of our patients forward to new heights.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
In the early 1600s, the French playwright Molière wrote one of the great satires of all time, “The Doctor in Spite of Himself.” In that play the main character, Sganarelle, is a woodcutter who wastes all his money on alcohol, so his wife Martine decides she will teach him a lesson. As she is plotting her revenge, Martine overhears two peasants discussing how they have been trying to find a doctor for their rich employer’s daughter, who has become suddenly mute. Martine seizes the opportunity to tell the peasants that her husband is a brilliant – though eccentric – doctor who usually hides his identity. Learning this, the peasants find Sganarelle and beg him to see their master’s daughter. Though he initially refuses, they berate him until he can take it no more, and he finally says that he is a doctor and agrees to assess the ill young woman.
Sganarelle does his best to impersonate a doctor while examining the young woman, and as he is doing so it becomes apparent even to him that she is not truly ill. She is pretending to be mute because she’s being forced to marry a wealthy man she does not love. Sganarelle discusses the diagnosis with her father, stating, “this impediment to the action of the tongue is caused by certain humors.” He goes on to say that her muteness was triggered by, “the vapors that pass from the left side, where the liver resides, to the right side, where the heart dwells.” The rich aristocrat listens intently and accepts the diagnosis, though he seems puzzled about one thing. “Isn’t the heart on the left side of the chest?” he asks. To this insightful and obvious question Sganarelle replies, “Yes, that used to be true; but we’ve changed all that, and we practice medicine now according to a whole new method.”
It is astonishing that Molière, in a farcical comedy written in the 1600s, could have anticipated the dizzying rate of change in modern medicine. While the heart and liver have not changed sides, the ways we are practicing medicine have undergone landmark shifts over the past 10 years. Just look at the new ways in which we record documentation, learn new information, send in prescriptions, manage populations in addition to individual patients, and so many other aspects of care. At times this evolution has its own satirical feel to it. For example, the notion that refusing to refill an opioid prescription for a patient that broke their opioid contract could lead to a bad review on Yelp or points off on a Press Ganey satisfaction survey does not seem reasonable, but it is real.
When we started this column about 10 years ago, we regularly received emails (and even letters written in fine penmanship and mailed in envelopes) from physicians who felt that the EHR was ruining their practice and their lives. Many of the letters talked about early retirement. Some physicians ended up retiring early. Many of these physicians were smart, able people who we believe took great care of patients. But as Leon C. Megginson, interpreting the work of Darwin, observed, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” Adaptability favors the young; the young have fewer habits to break, few preconceived ideas of how things should be, and perhaps more energy to give to new tasks.
We believe we have now reached the inflection point – a time in the history of an industry where an event (in this case the advent of the EHR) so fundamentally impacts the industry that the industry is changed from that point forward. The industry, and more importantly those who work in the industry, must adopt new approaches and attitudes in order to survive in the changed environment. Andrew Grove, the former CEO of Intel, talked about Strategic Inflection Points in a keynote address to the Academy of Management: “…what is common to [inflection points] and what is key is that they require a fundamental change in business strategy.” Grove also said, “That change can mean an opportunity to rise to new heights. But it may just as likely signal the beginning of the end.”
Up until recently, the introduction of the EHR lead to discussions about what was good and what was bad about the advent of EHRs. That time is past. We no longer receive letters from physicians expressing their concerns about the EHR, as many of those physicians have taken the change as a signal of the end of their careers, and chosen to retire. The rest have adapted to a new world. And in this new world we are certainly rising to new heights. We are forward-focused and looking at the multi-fold ways that our new technologies can accomplish their many missions – to improve the health of the population, to serve as a source of data to assess the real-world effectiveness of novel therapies, to evaluate and affect the quality of care given by practices and individual physicians, and to take excellent personalized care of individual patients. While we are physicians, not wood cutters as in Molière’s play, it remains incumbent upon us never to stop listening to our patients’ hearts, and to interpret their symptoms and signs with common sense, empathy and even humor when appropriate, all the while embracing approaches that move the health care of our patients forward to new heights.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
In the early 1600s, the French playwright Molière wrote one of the great satires of all time, “The Doctor in Spite of Himself.” In that play the main character, Sganarelle, is a woodcutter who wastes all his money on alcohol, so his wife Martine decides she will teach him a lesson. As she is plotting her revenge, Martine overhears two peasants discussing how they have been trying to find a doctor for their rich employer’s daughter, who has become suddenly mute. Martine seizes the opportunity to tell the peasants that her husband is a brilliant – though eccentric – doctor who usually hides his identity. Learning this, the peasants find Sganarelle and beg him to see their master’s daughter. Though he initially refuses, they berate him until he can take it no more, and he finally says that he is a doctor and agrees to assess the ill young woman.
Sganarelle does his best to impersonate a doctor while examining the young woman, and as he is doing so it becomes apparent even to him that she is not truly ill. She is pretending to be mute because she’s being forced to marry a wealthy man she does not love. Sganarelle discusses the diagnosis with her father, stating, “this impediment to the action of the tongue is caused by certain humors.” He goes on to say that her muteness was triggered by, “the vapors that pass from the left side, where the liver resides, to the right side, where the heart dwells.” The rich aristocrat listens intently and accepts the diagnosis, though he seems puzzled about one thing. “Isn’t the heart on the left side of the chest?” he asks. To this insightful and obvious question Sganarelle replies, “Yes, that used to be true; but we’ve changed all that, and we practice medicine now according to a whole new method.”
It is astonishing that Molière, in a farcical comedy written in the 1600s, could have anticipated the dizzying rate of change in modern medicine. While the heart and liver have not changed sides, the ways we are practicing medicine have undergone landmark shifts over the past 10 years. Just look at the new ways in which we record documentation, learn new information, send in prescriptions, manage populations in addition to individual patients, and so many other aspects of care. At times this evolution has its own satirical feel to it. For example, the notion that refusing to refill an opioid prescription for a patient that broke their opioid contract could lead to a bad review on Yelp or points off on a Press Ganey satisfaction survey does not seem reasonable, but it is real.
When we started this column about 10 years ago, we regularly received emails (and even letters written in fine penmanship and mailed in envelopes) from physicians who felt that the EHR was ruining their practice and their lives. Many of the letters talked about early retirement. Some physicians ended up retiring early. Many of these physicians were smart, able people who we believe took great care of patients. But as Leon C. Megginson, interpreting the work of Darwin, observed, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” Adaptability favors the young; the young have fewer habits to break, few preconceived ideas of how things should be, and perhaps more energy to give to new tasks.
We believe we have now reached the inflection point – a time in the history of an industry where an event (in this case the advent of the EHR) so fundamentally impacts the industry that the industry is changed from that point forward. The industry, and more importantly those who work in the industry, must adopt new approaches and attitudes in order to survive in the changed environment. Andrew Grove, the former CEO of Intel, talked about Strategic Inflection Points in a keynote address to the Academy of Management: “…what is common to [inflection points] and what is key is that they require a fundamental change in business strategy.” Grove also said, “That change can mean an opportunity to rise to new heights. But it may just as likely signal the beginning of the end.”
Up until recently, the introduction of the EHR lead to discussions about what was good and what was bad about the advent of EHRs. That time is past. We no longer receive letters from physicians expressing their concerns about the EHR, as many of those physicians have taken the change as a signal of the end of their careers, and chosen to retire. The rest have adapted to a new world. And in this new world we are certainly rising to new heights. We are forward-focused and looking at the multi-fold ways that our new technologies can accomplish their many missions – to improve the health of the population, to serve as a source of data to assess the real-world effectiveness of novel therapies, to evaluate and affect the quality of care given by practices and individual physicians, and to take excellent personalized care of individual patients. While we are physicians, not wood cutters as in Molière’s play, it remains incumbent upon us never to stop listening to our patients’ hearts, and to interpret their symptoms and signs with common sense, empathy and even humor when appropriate, all the while embracing approaches that move the health care of our patients forward to new heights.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
Now boarding: How we can skip coach and bump our patients up to first class
Cruising above the earth at 37,000 feet on the way back from vacation, my mind starts wandering. The impending reality of returning to work is setting in, and I can’t help but reflect on how the experience of a weary traveler trying to get home is like that of a weary patient trying to navigate modern health care. As it turns out, there are more than a few similarities, and that is not necessarily a good thing.
The modern airline industry is often cited by experts as a model for safety, efficiency, and innovation, though just a few decades ago this wasn’t the case. Several factors (for example, catastrophic crashes; the events of September 11th, 2001; the economic downturn) forced airlines to make radical improvements in how they operated – many of which I am quite thankful for as I gaze down upon America’s heartland from my window seat. Still, there are many who would say that in spite of (and sometimes because of) these improvements, air travel is the worst it’s ever been; airport lines are longer than ever, costs have steadily increased, and customer service has become little more than a quaint idea from a bygone era.
Most people deride the frustrations of air travel yet accept them as normal. The same expectations have unfortunately been set in health care. Patients wait, though waiting only contributes to anxiety and leads them to question the quality of their care. They also expect their journey to have many layover stops, though these involve even more waiting and often unnecessary redundancy. We need to streamline the care delivery process, and this is where technology can help.
First of all, we need to address the waiting. In health care, we tend to call this “access,” an ever-present problem for patients and providers. Thankfully, some recent innovations have helped significantly. The first of these innovations is online scheduling, which allows patients to find openings and schedule visits without the need to pick up the phone. Much like the ability to book a dinner reservation online, this is becoming an expectation for health care consumers. Participating practices and health systems can also use it as a marketing advantage; it is a fantastic way to recruit new patients as they search for a new provider online (that is, seeing that a physician has immediate openings may make the decision easier).
There are several companies providing third-party online scheduling services, and many of these can interface directly with electronic health records. EHR vendors themselves also provide this functionality to existing patients through an online web portal or mobile app. Either way, if you haven’t considered it yet, you should. It’s a great way to fill last-minute schedule openings and increase your patient base, all while improving access and patient satisfaction.
Another way to improve access is through telemedicine. We’ve written about this in prior columns, but it has certainly become more prevalent and available since then. Now more insurers are reimbursing for telemedicine services, and consumers are starting to embrace it as well. Consider some advantages: it’s more convenient for patients and often less expensive for those without insurance – cash prices tend to be in the $50-$75 range. It can also be more convenient for providers, as the typical telemedicine visit lasts only about 10 minutes and can be easily fit in last-minute. Better still, telemedicine can be a way for providers to now be paid for services they might have previously provided for free by telephone. It is critical to choose patients and conditions appropriate for these “virtual visits.” Medication checks, lab follow-ups, or rash evaluations are just a few examples, but with a little bit of thought it is easy to find dozens of other opportunities to use telemedicine to improve access.
In addition to access, we need to look for ways to improve efficiency and decrease redundancy when sending patients for testing and consultations. Recently, I had the experience of visiting a specialist for a minor medical issue. In spite of the fact that the specialist was a member of the same health system as my PCP, I still spent the first 15 minutes of my visit filling out paperwork that requested information easily available from my health record. There must be a better way.
Patients are beginning to question why, in the world of ubiquitous social media and connectivity, our computerized medical records can’t communicate. This is especially true when they are seeing physicians who are part of the same health system (as in my case). Thankfully, vendors have gotten the message and have begun allowing providers to collaborate, not only with physicians using the same software, but also with those using other EHRs through Health Information Exchanges (HIEs). Unfortunately, this alone won’t be enough. We must continue to promote the notion of patient-owned medical records, as that will be the only way to ensure true patient-centered care. In a future column, we’ll explore this concept in greater detail, but for now we’ll confirm our belief that universal interoperability is reasonable and possible.
As we are getting ready to land, I reflect on the wonderful vacation I just had and the tasks ahead at home, most of which I enjoy. Patients aren’t always as lucky; they are accessing medical care because they have to, not because they want to. Their “destination” is all too often an unfortunate diagnosis, unexpected surgical procedure, or lifetime of chronic discomfort. It is therefore incumbent on us, their care providers, to use the tools at our disposal to offer them the most efficient, most comfortable, and most connected journey possible.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
Cruising above the earth at 37,000 feet on the way back from vacation, my mind starts wandering. The impending reality of returning to work is setting in, and I can’t help but reflect on how the experience of a weary traveler trying to get home is like that of a weary patient trying to navigate modern health care. As it turns out, there are more than a few similarities, and that is not necessarily a good thing.
The modern airline industry is often cited by experts as a model for safety, efficiency, and innovation, though just a few decades ago this wasn’t the case. Several factors (for example, catastrophic crashes; the events of September 11th, 2001; the economic downturn) forced airlines to make radical improvements in how they operated – many of which I am quite thankful for as I gaze down upon America’s heartland from my window seat. Still, there are many who would say that in spite of (and sometimes because of) these improvements, air travel is the worst it’s ever been; airport lines are longer than ever, costs have steadily increased, and customer service has become little more than a quaint idea from a bygone era.
Most people deride the frustrations of air travel yet accept them as normal. The same expectations have unfortunately been set in health care. Patients wait, though waiting only contributes to anxiety and leads them to question the quality of their care. They also expect their journey to have many layover stops, though these involve even more waiting and often unnecessary redundancy. We need to streamline the care delivery process, and this is where technology can help.
First of all, we need to address the waiting. In health care, we tend to call this “access,” an ever-present problem for patients and providers. Thankfully, some recent innovations have helped significantly. The first of these innovations is online scheduling, which allows patients to find openings and schedule visits without the need to pick up the phone. Much like the ability to book a dinner reservation online, this is becoming an expectation for health care consumers. Participating practices and health systems can also use it as a marketing advantage; it is a fantastic way to recruit new patients as they search for a new provider online (that is, seeing that a physician has immediate openings may make the decision easier).
There are several companies providing third-party online scheduling services, and many of these can interface directly with electronic health records. EHR vendors themselves also provide this functionality to existing patients through an online web portal or mobile app. Either way, if you haven’t considered it yet, you should. It’s a great way to fill last-minute schedule openings and increase your patient base, all while improving access and patient satisfaction.
Another way to improve access is through telemedicine. We’ve written about this in prior columns, but it has certainly become more prevalent and available since then. Now more insurers are reimbursing for telemedicine services, and consumers are starting to embrace it as well. Consider some advantages: it’s more convenient for patients and often less expensive for those without insurance – cash prices tend to be in the $50-$75 range. It can also be more convenient for providers, as the typical telemedicine visit lasts only about 10 minutes and can be easily fit in last-minute. Better still, telemedicine can be a way for providers to now be paid for services they might have previously provided for free by telephone. It is critical to choose patients and conditions appropriate for these “virtual visits.” Medication checks, lab follow-ups, or rash evaluations are just a few examples, but with a little bit of thought it is easy to find dozens of other opportunities to use telemedicine to improve access.
In addition to access, we need to look for ways to improve efficiency and decrease redundancy when sending patients for testing and consultations. Recently, I had the experience of visiting a specialist for a minor medical issue. In spite of the fact that the specialist was a member of the same health system as my PCP, I still spent the first 15 minutes of my visit filling out paperwork that requested information easily available from my health record. There must be a better way.
Patients are beginning to question why, in the world of ubiquitous social media and connectivity, our computerized medical records can’t communicate. This is especially true when they are seeing physicians who are part of the same health system (as in my case). Thankfully, vendors have gotten the message and have begun allowing providers to collaborate, not only with physicians using the same software, but also with those using other EHRs through Health Information Exchanges (HIEs). Unfortunately, this alone won’t be enough. We must continue to promote the notion of patient-owned medical records, as that will be the only way to ensure true patient-centered care. In a future column, we’ll explore this concept in greater detail, but for now we’ll confirm our belief that universal interoperability is reasonable and possible.
As we are getting ready to land, I reflect on the wonderful vacation I just had and the tasks ahead at home, most of which I enjoy. Patients aren’t always as lucky; they are accessing medical care because they have to, not because they want to. Their “destination” is all too often an unfortunate diagnosis, unexpected surgical procedure, or lifetime of chronic discomfort. It is therefore incumbent on us, their care providers, to use the tools at our disposal to offer them the most efficient, most comfortable, and most connected journey possible.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
Cruising above the earth at 37,000 feet on the way back from vacation, my mind starts wandering. The impending reality of returning to work is setting in, and I can’t help but reflect on how the experience of a weary traveler trying to get home is like that of a weary patient trying to navigate modern health care. As it turns out, there are more than a few similarities, and that is not necessarily a good thing.
The modern airline industry is often cited by experts as a model for safety, efficiency, and innovation, though just a few decades ago this wasn’t the case. Several factors (for example, catastrophic crashes; the events of September 11th, 2001; the economic downturn) forced airlines to make radical improvements in how they operated – many of which I am quite thankful for as I gaze down upon America’s heartland from my window seat. Still, there are many who would say that in spite of (and sometimes because of) these improvements, air travel is the worst it’s ever been; airport lines are longer than ever, costs have steadily increased, and customer service has become little more than a quaint idea from a bygone era.
Most people deride the frustrations of air travel yet accept them as normal. The same expectations have unfortunately been set in health care. Patients wait, though waiting only contributes to anxiety and leads them to question the quality of their care. They also expect their journey to have many layover stops, though these involve even more waiting and often unnecessary redundancy. We need to streamline the care delivery process, and this is where technology can help.
First of all, we need to address the waiting. In health care, we tend to call this “access,” an ever-present problem for patients and providers. Thankfully, some recent innovations have helped significantly. The first of these innovations is online scheduling, which allows patients to find openings and schedule visits without the need to pick up the phone. Much like the ability to book a dinner reservation online, this is becoming an expectation for health care consumers. Participating practices and health systems can also use it as a marketing advantage; it is a fantastic way to recruit new patients as they search for a new provider online (that is, seeing that a physician has immediate openings may make the decision easier).
There are several companies providing third-party online scheduling services, and many of these can interface directly with electronic health records. EHR vendors themselves also provide this functionality to existing patients through an online web portal or mobile app. Either way, if you haven’t considered it yet, you should. It’s a great way to fill last-minute schedule openings and increase your patient base, all while improving access and patient satisfaction.
Another way to improve access is through telemedicine. We’ve written about this in prior columns, but it has certainly become more prevalent and available since then. Now more insurers are reimbursing for telemedicine services, and consumers are starting to embrace it as well. Consider some advantages: it’s more convenient for patients and often less expensive for those without insurance – cash prices tend to be in the $50-$75 range. It can also be more convenient for providers, as the typical telemedicine visit lasts only about 10 minutes and can be easily fit in last-minute. Better still, telemedicine can be a way for providers to now be paid for services they might have previously provided for free by telephone. It is critical to choose patients and conditions appropriate for these “virtual visits.” Medication checks, lab follow-ups, or rash evaluations are just a few examples, but with a little bit of thought it is easy to find dozens of other opportunities to use telemedicine to improve access.
In addition to access, we need to look for ways to improve efficiency and decrease redundancy when sending patients for testing and consultations. Recently, I had the experience of visiting a specialist for a minor medical issue. In spite of the fact that the specialist was a member of the same health system as my PCP, I still spent the first 15 minutes of my visit filling out paperwork that requested information easily available from my health record. There must be a better way.
Patients are beginning to question why, in the world of ubiquitous social media and connectivity, our computerized medical records can’t communicate. This is especially true when they are seeing physicians who are part of the same health system (as in my case). Thankfully, vendors have gotten the message and have begun allowing providers to collaborate, not only with physicians using the same software, but also with those using other EHRs through Health Information Exchanges (HIEs). Unfortunately, this alone won’t be enough. We must continue to promote the notion of patient-owned medical records, as that will be the only way to ensure true patient-centered care. In a future column, we’ll explore this concept in greater detail, but for now we’ll confirm our belief that universal interoperability is reasonable and possible.
As we are getting ready to land, I reflect on the wonderful vacation I just had and the tasks ahead at home, most of which I enjoy. Patients aren’t always as lucky; they are accessing medical care because they have to, not because they want to. Their “destination” is all too often an unfortunate diagnosis, unexpected surgical procedure, or lifetime of chronic discomfort. It is therefore incumbent on us, their care providers, to use the tools at our disposal to offer them the most efficient, most comfortable, and most connected journey possible.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.
EHR Report: Don’t let the electronic health record do the driving
The secret to the care of the patient ... is in caring for the patient.
-Francis W. Peabody, MD1
Last month I received a call from a man who was upset about the way he was treated in our office. He had presented with depression and felt insulted by one of our resident physicians in the way he had interacted with him during his visit. I offered to see him the next day.
When I walked into the exam room, I noticed that his eyes were bloodshot and he was fidgeting in his chair. He explained that it was difficult for him to address this issue, but he had been taken aback at his previous visit to our office when the doctor who saw him, after introducing himself, proceeded to sit down, open his computer, and start typing. The patient went on to describe that the physician – while staring at his computer screen – first acknowledged that he was being seen for depression and then immediately asked him if he had any plans to commit suicide. He did not have any suicidal plans, but he felt strongly that being asked about suicide as the first question in the doctor’s interview missed the point of his visit. He was having trouble concentrating, he felt down, and he was having difficulty sleeping at night, all contributing to trouble both at work and in his personal life. Suicide was not a concern of his. He shook his head. He said he understood that we, as doctors, had to put information into the computer, but he also felt that the doctor’s main goal during that visit appeared to be to get through the forms on the computer rather than taking care of him. He admonished that physicians also need to remember that there is a patient in the room and that we should pay attention to the patient first. The computer should be second. I couldn’t have said it better myself. I told him that I would look into what happened, and then we continued with his visit.
You can already see where this discussion is going. The odd thing about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare’s quality payment program, is that, unless we are careful, the result of the program may be the opposite of what it’s intended to accomplish. By leading to an over-focus on documentation of the quality of care, we are at risk of diminishing the quality of care itself. In essence, many of the requirements appear to simply be more advanced versions of the meaningful (meaningless?) use provisions with which we have previously grappled. It is clear that we should assess the quality of care that is given and that physician payment should be influenced by that care. It is also clear that the only reasonable way to measure the care provided is by collecting data from the EHR. The problem is that the sophistication of the EHR has not caught up to the sophistication of our goals.
Our challenge as physicians who care for patients therefore occurs at an individual level for each of us. How do we provide the necessary documentation scattered throughout our digital charts to satisfy reporting requirements, yet still meet the very real needs of patients to have their voices heard and their emotions acknowledged? The Physician Charter by the American Board of Internal Medicine discusses “the primacy of patient welfare” as a core tenant of medical practice. It goes on to state that “administrative exigencies must not compromise this principle.”2 Given competing demands, how do we continue to accomplish these goals which are often in conflict with one another?
We cannot provide an answer to this question because unfortunately – or perhaps fortunately – the answer does not come in the form of a clear algorithm of behaviors or a form that we can click on. However that does not mean that it cannot be done. Simply being mindful of how important personal interaction is to our patients will help us stay focused on patient needs. In fact, one of the most exciting aspects of our digital age (and our use of EHRs) is that the need to actually connect with people is more important than ever, and prioritizing this stands to reward those individuals who continue to pay attention to patients. In a future column, we will discuss suggestions and strategies for integrating the EHR into truly patient-centered care. In the early 1920s, Dr. Francis W. Peabody said, “The treatment of a disease may be entirely impersonal: the care of the patient must be completely personal.”1 Medical competency is essential and documentation is required, but neither alone is sufficient for the care of patients.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. Peabody FW. The care of the patient. JAMA. 1927;88:877-82.
2. The Physician Charter. American Board of Internal Medicine Foundation at http://abimfoundation.org/what-we-do/physician-charter.
The secret to the care of the patient ... is in caring for the patient.
-Francis W. Peabody, MD1
Last month I received a call from a man who was upset about the way he was treated in our office. He had presented with depression and felt insulted by one of our resident physicians in the way he had interacted with him during his visit. I offered to see him the next day.
When I walked into the exam room, I noticed that his eyes were bloodshot and he was fidgeting in his chair. He explained that it was difficult for him to address this issue, but he had been taken aback at his previous visit to our office when the doctor who saw him, after introducing himself, proceeded to sit down, open his computer, and start typing. The patient went on to describe that the physician – while staring at his computer screen – first acknowledged that he was being seen for depression and then immediately asked him if he had any plans to commit suicide. He did not have any suicidal plans, but he felt strongly that being asked about suicide as the first question in the doctor’s interview missed the point of his visit. He was having trouble concentrating, he felt down, and he was having difficulty sleeping at night, all contributing to trouble both at work and in his personal life. Suicide was not a concern of his. He shook his head. He said he understood that we, as doctors, had to put information into the computer, but he also felt that the doctor’s main goal during that visit appeared to be to get through the forms on the computer rather than taking care of him. He admonished that physicians also need to remember that there is a patient in the room and that we should pay attention to the patient first. The computer should be second. I couldn’t have said it better myself. I told him that I would look into what happened, and then we continued with his visit.
You can already see where this discussion is going. The odd thing about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare’s quality payment program, is that, unless we are careful, the result of the program may be the opposite of what it’s intended to accomplish. By leading to an over-focus on documentation of the quality of care, we are at risk of diminishing the quality of care itself. In essence, many of the requirements appear to simply be more advanced versions of the meaningful (meaningless?) use provisions with which we have previously grappled. It is clear that we should assess the quality of care that is given and that physician payment should be influenced by that care. It is also clear that the only reasonable way to measure the care provided is by collecting data from the EHR. The problem is that the sophistication of the EHR has not caught up to the sophistication of our goals.
Our challenge as physicians who care for patients therefore occurs at an individual level for each of us. How do we provide the necessary documentation scattered throughout our digital charts to satisfy reporting requirements, yet still meet the very real needs of patients to have their voices heard and their emotions acknowledged? The Physician Charter by the American Board of Internal Medicine discusses “the primacy of patient welfare” as a core tenant of medical practice. It goes on to state that “administrative exigencies must not compromise this principle.”2 Given competing demands, how do we continue to accomplish these goals which are often in conflict with one another?
We cannot provide an answer to this question because unfortunately – or perhaps fortunately – the answer does not come in the form of a clear algorithm of behaviors or a form that we can click on. However that does not mean that it cannot be done. Simply being mindful of how important personal interaction is to our patients will help us stay focused on patient needs. In fact, one of the most exciting aspects of our digital age (and our use of EHRs) is that the need to actually connect with people is more important than ever, and prioritizing this stands to reward those individuals who continue to pay attention to patients. In a future column, we will discuss suggestions and strategies for integrating the EHR into truly patient-centered care. In the early 1920s, Dr. Francis W. Peabody said, “The treatment of a disease may be entirely impersonal: the care of the patient must be completely personal.”1 Medical competency is essential and documentation is required, but neither alone is sufficient for the care of patients.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. Peabody FW. The care of the patient. JAMA. 1927;88:877-82.
2. The Physician Charter. American Board of Internal Medicine Foundation at http://abimfoundation.org/what-we-do/physician-charter.
The secret to the care of the patient ... is in caring for the patient.
-Francis W. Peabody, MD1
Last month I received a call from a man who was upset about the way he was treated in our office. He had presented with depression and felt insulted by one of our resident physicians in the way he had interacted with him during his visit. I offered to see him the next day.
When I walked into the exam room, I noticed that his eyes were bloodshot and he was fidgeting in his chair. He explained that it was difficult for him to address this issue, but he had been taken aback at his previous visit to our office when the doctor who saw him, after introducing himself, proceeded to sit down, open his computer, and start typing. The patient went on to describe that the physician – while staring at his computer screen – first acknowledged that he was being seen for depression and then immediately asked him if he had any plans to commit suicide. He did not have any suicidal plans, but he felt strongly that being asked about suicide as the first question in the doctor’s interview missed the point of his visit. He was having trouble concentrating, he felt down, and he was having difficulty sleeping at night, all contributing to trouble both at work and in his personal life. Suicide was not a concern of his. He shook his head. He said he understood that we, as doctors, had to put information into the computer, but he also felt that the doctor’s main goal during that visit appeared to be to get through the forms on the computer rather than taking care of him. He admonished that physicians also need to remember that there is a patient in the room and that we should pay attention to the patient first. The computer should be second. I couldn’t have said it better myself. I told him that I would look into what happened, and then we continued with his visit.
You can already see where this discussion is going. The odd thing about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare’s quality payment program, is that, unless we are careful, the result of the program may be the opposite of what it’s intended to accomplish. By leading to an over-focus on documentation of the quality of care, we are at risk of diminishing the quality of care itself. In essence, many of the requirements appear to simply be more advanced versions of the meaningful (meaningless?) use provisions with which we have previously grappled. It is clear that we should assess the quality of care that is given and that physician payment should be influenced by that care. It is also clear that the only reasonable way to measure the care provided is by collecting data from the EHR. The problem is that the sophistication of the EHR has not caught up to the sophistication of our goals.
Our challenge as physicians who care for patients therefore occurs at an individual level for each of us. How do we provide the necessary documentation scattered throughout our digital charts to satisfy reporting requirements, yet still meet the very real needs of patients to have their voices heard and their emotions acknowledged? The Physician Charter by the American Board of Internal Medicine discusses “the primacy of patient welfare” as a core tenant of medical practice. It goes on to state that “administrative exigencies must not compromise this principle.”2 Given competing demands, how do we continue to accomplish these goals which are often in conflict with one another?
We cannot provide an answer to this question because unfortunately – or perhaps fortunately – the answer does not come in the form of a clear algorithm of behaviors or a form that we can click on. However that does not mean that it cannot be done. Simply being mindful of how important personal interaction is to our patients will help us stay focused on patient needs. In fact, one of the most exciting aspects of our digital age (and our use of EHRs) is that the need to actually connect with people is more important than ever, and prioritizing this stands to reward those individuals who continue to pay attention to patients. In a future column, we will discuss suggestions and strategies for integrating the EHR into truly patient-centered care. In the early 1920s, Dr. Francis W. Peabody said, “The treatment of a disease may be entirely impersonal: the care of the patient must be completely personal.”1 Medical competency is essential and documentation is required, but neither alone is sufficient for the care of patients.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. Peabody FW. The care of the patient. JAMA. 1927;88:877-82.
2. The Physician Charter. American Board of Internal Medicine Foundation at http://abimfoundation.org/what-we-do/physician-charter.
Restoring the promise of (really) meaningful use
When we started publishing the EHR Report several years ago, our very first column was a brief overview of a new federal incentive program known as Meaningful Use. At that time, the prospect of receiving thousands of dollars to adopt an electronic health record seemed exciting, and our dream of health care’s digital future appeared to be coming true.
Best of all, we as physicians would be paid to simply embrace it!
Unfortunately, it wasn’t long before that dream (for many at least) devolved into a nightmare. Electronic health records hadn’t been designed to fit into physicians’ long-established work flows, and just weren’t up to the challenge of increasing efficiency. In fact, EHRs quickly became virtual taskmasters, leaving physicians mired in a sea of clicks and slow-moving screens.
Frankly speaking, Meaningful Use hasn’t lived up to its promises. With measures obligating users to fill in a myriad of check-boxes and document often irrelevant information, the program has seemed less like an incentive and more like a penance.
To top it off, the all-or-nothing requirement has meant that – after a year of hard work – providers missing even one goal receive no payments at all, and instead are assessed financial penalties!
All of this has appropriately led physicians to become jaded – not excited – about the digital future.
Thankfully, there is reason for hope: 2017 marks the end of Meaningful Use under Medicare.
What’s new for 2017?
MACRA has a much grander scope and sets an even loftier goal: transforming care delivery to achieve better value and ultimately healthier patients.
Now, in case you’re not already confused by the number of programs cited above, there is one more we need to mention to explain the future of EHR incentives: the Merit-based Incentive Payment System, or MIPS, one of two tracks in the Quality Payment Program.
The majority of Medicare providers will choose this track, which focuses on four major components to determine reimbursement incentives: quality, improvement activities, advancing care information, and cost.
Depending on performance in each of these areas, participants will see a variable payment adjustment (upward or downward) in subsequent years (this is a percentage of Medicare payments that increases annually, beginning with a possible +/– 4% in 2019, to a maximum of +/– 9% in 2022).
Providers under MIPS who choose to attest for this year can select from three levels of participation:
1. Test: submission of only a minimal amount of 2017 data (such as one or two measures) to avoid penalty.
2. Partial: submission of 90 days’ worth of data, which may result in a neutral or positive payment adjustment (and may even earn the max adjustment).
3. Full: submission of a full year of data.
Here’s an example of how this will work: A provider who attests in March 2018 for the full 2017 year and does really well could see up to a 4% incentive bonus on Medicare payments in 2019. A provider who chooses not to attest would receive a penalty of 4%.
It’s worth noting here that MIPS expands upon the inclusion criteria set for Meaningful Use under Medicare. Medicare Part B clinicians are eligible to participate if they bill $30,000 in charges and see at least 100 Medicare patients annually. MIPS also broadens the list of eligible provider types. Physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists are all able to attest.
Advancing Care Information
Under MIPS, Meaningful Use is replaced by an initiative called Advancing Care Information, or ACI. In this new incarnation, there are fewer required measures, and they are much less onerous than they were under the former program.
Also, there are a number of optional measures. A provider may choose to attest to these nonrequired metrics to improve his or her chances of achieving the maximum incentive, but it isn’t necessary. There are also bonus measures involving public health registry reporting. These are optional but a sure bet to increase incentives. In all, the ACI component composes 25% of a provider’s final MIPS score.
For 2017, participants are able to choose one of two tracks in the ACI program, depending on their EHR’s certification year. (If you are confused by this or don’t know the status of your product, check with your vendor or go to https://chpl.healthit.gov to figure it out).
Providers with technology certified to the 2015 edition (or a combination of technologies from the 2014 and 2015 editions) can fully attest to the ACI objectives and measures or elect to use the transition objectives and measures. Those with 2014 edition software must choose the transition measures.
We will cover the specific measures in a future column, but for now we’ll note that both tracks are very similar and focus on protecting patient data, encouraging patient access to their own records, and sharing information electronically with other providers.
Rekindling the dream
We are certain that changing legislation won’t solve all of the problems inherent in current EHR systems, but we are always encouraged by any attempt to reduce the documentation burden on physicians. By eschewing thresholds, eliminating the all-or-nothing requirement, and reducing the number of required measures, the ACI program does seem to shift the focus away from volume and toward value.
That alone has the potential to restore our hope of a brighter future, and make our use of electronic health records significantly more meaningful.
Note: To learn more about Quality Payment Program and MIPS, we highly recommend an online resource published by the Centers for Medicare & Medicaid Services that is easy to follow and is full of useful information. It can be found at https://qpp.cms.gov.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.
When we started publishing the EHR Report several years ago, our very first column was a brief overview of a new federal incentive program known as Meaningful Use. At that time, the prospect of receiving thousands of dollars to adopt an electronic health record seemed exciting, and our dream of health care’s digital future appeared to be coming true.
Best of all, we as physicians would be paid to simply embrace it!
Unfortunately, it wasn’t long before that dream (for many at least) devolved into a nightmare. Electronic health records hadn’t been designed to fit into physicians’ long-established work flows, and just weren’t up to the challenge of increasing efficiency. In fact, EHRs quickly became virtual taskmasters, leaving physicians mired in a sea of clicks and slow-moving screens.
Frankly speaking, Meaningful Use hasn’t lived up to its promises. With measures obligating users to fill in a myriad of check-boxes and document often irrelevant information, the program has seemed less like an incentive and more like a penance.
To top it off, the all-or-nothing requirement has meant that – after a year of hard work – providers missing even one goal receive no payments at all, and instead are assessed financial penalties!
All of this has appropriately led physicians to become jaded – not excited – about the digital future.
Thankfully, there is reason for hope: 2017 marks the end of Meaningful Use under Medicare.
What’s new for 2017?
MACRA has a much grander scope and sets an even loftier goal: transforming care delivery to achieve better value and ultimately healthier patients.
Now, in case you’re not already confused by the number of programs cited above, there is one more we need to mention to explain the future of EHR incentives: the Merit-based Incentive Payment System, or MIPS, one of two tracks in the Quality Payment Program.
The majority of Medicare providers will choose this track, which focuses on four major components to determine reimbursement incentives: quality, improvement activities, advancing care information, and cost.
Depending on performance in each of these areas, participants will see a variable payment adjustment (upward or downward) in subsequent years (this is a percentage of Medicare payments that increases annually, beginning with a possible +/– 4% in 2019, to a maximum of +/– 9% in 2022).
Providers under MIPS who choose to attest for this year can select from three levels of participation:
1. Test: submission of only a minimal amount of 2017 data (such as one or two measures) to avoid penalty.
2. Partial: submission of 90 days’ worth of data, which may result in a neutral or positive payment adjustment (and may even earn the max adjustment).
3. Full: submission of a full year of data.
Here’s an example of how this will work: A provider who attests in March 2018 for the full 2017 year and does really well could see up to a 4% incentive bonus on Medicare payments in 2019. A provider who chooses not to attest would receive a penalty of 4%.
It’s worth noting here that MIPS expands upon the inclusion criteria set for Meaningful Use under Medicare. Medicare Part B clinicians are eligible to participate if they bill $30,000 in charges and see at least 100 Medicare patients annually. MIPS also broadens the list of eligible provider types. Physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists are all able to attest.
Advancing Care Information
Under MIPS, Meaningful Use is replaced by an initiative called Advancing Care Information, or ACI. In this new incarnation, there are fewer required measures, and they are much less onerous than they were under the former program.
Also, there are a number of optional measures. A provider may choose to attest to these nonrequired metrics to improve his or her chances of achieving the maximum incentive, but it isn’t necessary. There are also bonus measures involving public health registry reporting. These are optional but a sure bet to increase incentives. In all, the ACI component composes 25% of a provider’s final MIPS score.
For 2017, participants are able to choose one of two tracks in the ACI program, depending on their EHR’s certification year. (If you are confused by this or don’t know the status of your product, check with your vendor or go to https://chpl.healthit.gov to figure it out).
Providers with technology certified to the 2015 edition (or a combination of technologies from the 2014 and 2015 editions) can fully attest to the ACI objectives and measures or elect to use the transition objectives and measures. Those with 2014 edition software must choose the transition measures.
We will cover the specific measures in a future column, but for now we’ll note that both tracks are very similar and focus on protecting patient data, encouraging patient access to their own records, and sharing information electronically with other providers.
Rekindling the dream
We are certain that changing legislation won’t solve all of the problems inherent in current EHR systems, but we are always encouraged by any attempt to reduce the documentation burden on physicians. By eschewing thresholds, eliminating the all-or-nothing requirement, and reducing the number of required measures, the ACI program does seem to shift the focus away from volume and toward value.
That alone has the potential to restore our hope of a brighter future, and make our use of electronic health records significantly more meaningful.
Note: To learn more about Quality Payment Program and MIPS, we highly recommend an online resource published by the Centers for Medicare & Medicaid Services that is easy to follow and is full of useful information. It can be found at https://qpp.cms.gov.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.
When we started publishing the EHR Report several years ago, our very first column was a brief overview of a new federal incentive program known as Meaningful Use. At that time, the prospect of receiving thousands of dollars to adopt an electronic health record seemed exciting, and our dream of health care’s digital future appeared to be coming true.
Best of all, we as physicians would be paid to simply embrace it!
Unfortunately, it wasn’t long before that dream (for many at least) devolved into a nightmare. Electronic health records hadn’t been designed to fit into physicians’ long-established work flows, and just weren’t up to the challenge of increasing efficiency. In fact, EHRs quickly became virtual taskmasters, leaving physicians mired in a sea of clicks and slow-moving screens.
Frankly speaking, Meaningful Use hasn’t lived up to its promises. With measures obligating users to fill in a myriad of check-boxes and document often irrelevant information, the program has seemed less like an incentive and more like a penance.
To top it off, the all-or-nothing requirement has meant that – after a year of hard work – providers missing even one goal receive no payments at all, and instead are assessed financial penalties!
All of this has appropriately led physicians to become jaded – not excited – about the digital future.
Thankfully, there is reason for hope: 2017 marks the end of Meaningful Use under Medicare.
What’s new for 2017?
MACRA has a much grander scope and sets an even loftier goal: transforming care delivery to achieve better value and ultimately healthier patients.
Now, in case you’re not already confused by the number of programs cited above, there is one more we need to mention to explain the future of EHR incentives: the Merit-based Incentive Payment System, or MIPS, one of two tracks in the Quality Payment Program.
The majority of Medicare providers will choose this track, which focuses on four major components to determine reimbursement incentives: quality, improvement activities, advancing care information, and cost.
Depending on performance in each of these areas, participants will see a variable payment adjustment (upward or downward) in subsequent years (this is a percentage of Medicare payments that increases annually, beginning with a possible +/– 4% in 2019, to a maximum of +/– 9% in 2022).
Providers under MIPS who choose to attest for this year can select from three levels of participation:
1. Test: submission of only a minimal amount of 2017 data (such as one or two measures) to avoid penalty.
2. Partial: submission of 90 days’ worth of data, which may result in a neutral or positive payment adjustment (and may even earn the max adjustment).
3. Full: submission of a full year of data.
Here’s an example of how this will work: A provider who attests in March 2018 for the full 2017 year and does really well could see up to a 4% incentive bonus on Medicare payments in 2019. A provider who chooses not to attest would receive a penalty of 4%.
It’s worth noting here that MIPS expands upon the inclusion criteria set for Meaningful Use under Medicare. Medicare Part B clinicians are eligible to participate if they bill $30,000 in charges and see at least 100 Medicare patients annually. MIPS also broadens the list of eligible provider types. Physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists are all able to attest.
Advancing Care Information
Under MIPS, Meaningful Use is replaced by an initiative called Advancing Care Information, or ACI. In this new incarnation, there are fewer required measures, and they are much less onerous than they were under the former program.
Also, there are a number of optional measures. A provider may choose to attest to these nonrequired metrics to improve his or her chances of achieving the maximum incentive, but it isn’t necessary. There are also bonus measures involving public health registry reporting. These are optional but a sure bet to increase incentives. In all, the ACI component composes 25% of a provider’s final MIPS score.
For 2017, participants are able to choose one of two tracks in the ACI program, depending on their EHR’s certification year. (If you are confused by this or don’t know the status of your product, check with your vendor or go to https://chpl.healthit.gov to figure it out).
Providers with technology certified to the 2015 edition (or a combination of technologies from the 2014 and 2015 editions) can fully attest to the ACI objectives and measures or elect to use the transition objectives and measures. Those with 2014 edition software must choose the transition measures.
We will cover the specific measures in a future column, but for now we’ll note that both tracks are very similar and focus on protecting patient data, encouraging patient access to their own records, and sharing information electronically with other providers.
Rekindling the dream
We are certain that changing legislation won’t solve all of the problems inherent in current EHR systems, but we are always encouraged by any attempt to reduce the documentation burden on physicians. By eschewing thresholds, eliminating the all-or-nothing requirement, and reducing the number of required measures, the ACI program does seem to shift the focus away from volume and toward value.
That alone has the potential to restore our hope of a brighter future, and make our use of electronic health records significantly more meaningful.
Note: To learn more about Quality Payment Program and MIPS, we highly recommend an online resource published by the Centers for Medicare & Medicaid Services that is easy to follow and is full of useful information. It can be found at https://qpp.cms.gov.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health.
Two boys, a dog, and our electronic health records
“Speak clearly, if you speak at all; carve every word before you let it fall.” – Oliver Wendell Holmes Sr.
One of our favorite stories is that of two boys talking to one another with a dog sitting nearby. One boy says to the other, “I taught my dog how to whistle.” Skeptically, the other boy responds, “Really? I don’t hear him whistling.” The first boys then replies, “I said I taught him. I didn’t say he learned!”
We spend a lot of time as physicians going over information with our patients, yet, according to the best data available, they retain only a small portion of what we tell them. Medication adherence rates for chronic disease range from 30% to 70%, showing that many doses of important medications are missed. Patients often don’t even remember the last instructions we give them as they are walking out of the office. This raises questions about both the way we explain information and how we can use the tools at our disposal to enhance the communication so vital to patient outcomes.
Obviously, we need to consider our words carefully and focus on teaching, not just speaking. What sets teaching apart from speaking is consideration of the learner. The better we understand our patients’ perspectives, the better the knowledge transfer will be. A simple way to address this may be better eye contact.
We have all heard the expression “the eyes are a window to the soul.” Yet, we now have computers that acts as a virtual shades, covering that window and drawing our gaze away from our patients. These shades can blind us to important clues, impeding communication and leading to misunderstanding, missed opportunity, and even patient harm. This is why some practices have chosen to use scribes to handle documentation, freeing up physicians’ eyes and addressing another obstacle to communication: time.
One of the most cited complaints from physicians is lack of time. There is an ever-growing demand on us to see more patients, manage more data, and “check off more boxes” to meet bureaucratic requirements. It should come as no surprise that these impede good patient care. We are thankful that attempts to modernize payment models are recognizing this problem. For example, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) helps to blaze the trail by focusing on care quality, practice improvement, and patient satisfaction for incentive payments. While these are early steps, they certainly point to a future more concerned with value than with volume.
As we move toward that future, we need to acknowledge that information technology can be both the problem and the answer. The current state of health IT is far from perfect. The tools we use have been designed, seemingly, around financial performance or developed to meet government requirements. It appears that neither physicians nor patients were consulted to ensure their usability or utility. Step No. 1 was getting EHRs out there. Steps 2-10 will be making them useful to clinicians, patients, and health care systems. Part of that utility will come in their ability to enhance communication.
Take patient portals, for example. The “meaningful use program” set as a requirement the ability for patients to “view, download, or transmit” their health information through electronic means. EHR vendors complied with this request but seem to have missed the intent of the measure. Patients accessing the information often are confronted with a morass of technical jargon and unfamiliar medical terms, which may even be offensive. For example, we recently spoke to a parent of a teenager with moderate intellectual disabilities. A hold-out ICD-9 code on the teen’s chart translated to her portal as “318.0 – Imbecile.” Her mother was appropriately upset, and she decided to leave the practice.
As we begin to understand technology’s advantages – and learn its pitfalls – we believe EHR vendors must enhance their offerings while engaging both providers and patients in the process of improvement. We also believe physicians need to leverage the entire care team to realize the software’s full potential. This approach may present new challenges in communication, but it also presents new opportunities. We hope that this collaborative approach will allow physicians to have more time to spend connecting with patients, leading to enhanced understanding and satisfaction.
Our knowledge of human health and disease is growing more sophisticated and so is the challenge of imparting that knowledge to patients. It is critical to find ways to do so that are relevant and understandable and give patients the tools they need to reinforce and remember what we say. This is one of the promises that we are just beginning to see fulfilled by modern EHR technology. Unlike the boy who was trying to teach his dog to whistle, our words have deep impact, and our roles as educators have never been more important.
This article was updated 3/24/17.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
“Speak clearly, if you speak at all; carve every word before you let it fall.” – Oliver Wendell Holmes Sr.
One of our favorite stories is that of two boys talking to one another with a dog sitting nearby. One boy says to the other, “I taught my dog how to whistle.” Skeptically, the other boy responds, “Really? I don’t hear him whistling.” The first boys then replies, “I said I taught him. I didn’t say he learned!”
We spend a lot of time as physicians going over information with our patients, yet, according to the best data available, they retain only a small portion of what we tell them. Medication adherence rates for chronic disease range from 30% to 70%, showing that many doses of important medications are missed. Patients often don’t even remember the last instructions we give them as they are walking out of the office. This raises questions about both the way we explain information and how we can use the tools at our disposal to enhance the communication so vital to patient outcomes.
Obviously, we need to consider our words carefully and focus on teaching, not just speaking. What sets teaching apart from speaking is consideration of the learner. The better we understand our patients’ perspectives, the better the knowledge transfer will be. A simple way to address this may be better eye contact.
We have all heard the expression “the eyes are a window to the soul.” Yet, we now have computers that acts as a virtual shades, covering that window and drawing our gaze away from our patients. These shades can blind us to important clues, impeding communication and leading to misunderstanding, missed opportunity, and even patient harm. This is why some practices have chosen to use scribes to handle documentation, freeing up physicians’ eyes and addressing another obstacle to communication: time.
One of the most cited complaints from physicians is lack of time. There is an ever-growing demand on us to see more patients, manage more data, and “check off more boxes” to meet bureaucratic requirements. It should come as no surprise that these impede good patient care. We are thankful that attempts to modernize payment models are recognizing this problem. For example, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) helps to blaze the trail by focusing on care quality, practice improvement, and patient satisfaction for incentive payments. While these are early steps, they certainly point to a future more concerned with value than with volume.
As we move toward that future, we need to acknowledge that information technology can be both the problem and the answer. The current state of health IT is far from perfect. The tools we use have been designed, seemingly, around financial performance or developed to meet government requirements. It appears that neither physicians nor patients were consulted to ensure their usability or utility. Step No. 1 was getting EHRs out there. Steps 2-10 will be making them useful to clinicians, patients, and health care systems. Part of that utility will come in their ability to enhance communication.
Take patient portals, for example. The “meaningful use program” set as a requirement the ability for patients to “view, download, or transmit” their health information through electronic means. EHR vendors complied with this request but seem to have missed the intent of the measure. Patients accessing the information often are confronted with a morass of technical jargon and unfamiliar medical terms, which may even be offensive. For example, we recently spoke to a parent of a teenager with moderate intellectual disabilities. A hold-out ICD-9 code on the teen’s chart translated to her portal as “318.0 – Imbecile.” Her mother was appropriately upset, and she decided to leave the practice.
As we begin to understand technology’s advantages – and learn its pitfalls – we believe EHR vendors must enhance their offerings while engaging both providers and patients in the process of improvement. We also believe physicians need to leverage the entire care team to realize the software’s full potential. This approach may present new challenges in communication, but it also presents new opportunities. We hope that this collaborative approach will allow physicians to have more time to spend connecting with patients, leading to enhanced understanding and satisfaction.
Our knowledge of human health and disease is growing more sophisticated and so is the challenge of imparting that knowledge to patients. It is critical to find ways to do so that are relevant and understandable and give patients the tools they need to reinforce and remember what we say. This is one of the promises that we are just beginning to see fulfilled by modern EHR technology. Unlike the boy who was trying to teach his dog to whistle, our words have deep impact, and our roles as educators have never been more important.
This article was updated 3/24/17.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
“Speak clearly, if you speak at all; carve every word before you let it fall.” – Oliver Wendell Holmes Sr.
One of our favorite stories is that of two boys talking to one another with a dog sitting nearby. One boy says to the other, “I taught my dog how to whistle.” Skeptically, the other boy responds, “Really? I don’t hear him whistling.” The first boys then replies, “I said I taught him. I didn’t say he learned!”
We spend a lot of time as physicians going over information with our patients, yet, according to the best data available, they retain only a small portion of what we tell them. Medication adherence rates for chronic disease range from 30% to 70%, showing that many doses of important medications are missed. Patients often don’t even remember the last instructions we give them as they are walking out of the office. This raises questions about both the way we explain information and how we can use the tools at our disposal to enhance the communication so vital to patient outcomes.
Obviously, we need to consider our words carefully and focus on teaching, not just speaking. What sets teaching apart from speaking is consideration of the learner. The better we understand our patients’ perspectives, the better the knowledge transfer will be. A simple way to address this may be better eye contact.
We have all heard the expression “the eyes are a window to the soul.” Yet, we now have computers that acts as a virtual shades, covering that window and drawing our gaze away from our patients. These shades can blind us to important clues, impeding communication and leading to misunderstanding, missed opportunity, and even patient harm. This is why some practices have chosen to use scribes to handle documentation, freeing up physicians’ eyes and addressing another obstacle to communication: time.
One of the most cited complaints from physicians is lack of time. There is an ever-growing demand on us to see more patients, manage more data, and “check off more boxes” to meet bureaucratic requirements. It should come as no surprise that these impede good patient care. We are thankful that attempts to modernize payment models are recognizing this problem. For example, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) helps to blaze the trail by focusing on care quality, practice improvement, and patient satisfaction for incentive payments. While these are early steps, they certainly point to a future more concerned with value than with volume.
As we move toward that future, we need to acknowledge that information technology can be both the problem and the answer. The current state of health IT is far from perfect. The tools we use have been designed, seemingly, around financial performance or developed to meet government requirements. It appears that neither physicians nor patients were consulted to ensure their usability or utility. Step No. 1 was getting EHRs out there. Steps 2-10 will be making them useful to clinicians, patients, and health care systems. Part of that utility will come in their ability to enhance communication.
Take patient portals, for example. The “meaningful use program” set as a requirement the ability for patients to “view, download, or transmit” their health information through electronic means. EHR vendors complied with this request but seem to have missed the intent of the measure. Patients accessing the information often are confronted with a morass of technical jargon and unfamiliar medical terms, which may even be offensive. For example, we recently spoke to a parent of a teenager with moderate intellectual disabilities. A hold-out ICD-9 code on the teen’s chart translated to her portal as “318.0 – Imbecile.” Her mother was appropriately upset, and she decided to leave the practice.
As we begin to understand technology’s advantages – and learn its pitfalls – we believe EHR vendors must enhance their offerings while engaging both providers and patients in the process of improvement. We also believe physicians need to leverage the entire care team to realize the software’s full potential. This approach may present new challenges in communication, but it also presents new opportunities. We hope that this collaborative approach will allow physicians to have more time to spend connecting with patients, leading to enhanced understanding and satisfaction.
Our knowledge of human health and disease is growing more sophisticated and so is the challenge of imparting that knowledge to patients. It is critical to find ways to do so that are relevant and understandable and give patients the tools they need to reinforce and remember what we say. This is one of the promises that we are just beginning to see fulfilled by modern EHR technology. Unlike the boy who was trying to teach his dog to whistle, our words have deep impact, and our roles as educators have never been more important.
This article was updated 3/24/17.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Our new year’s resolutions
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Here on Earth
We live inundated with promises that technology will solve our most challenging problems, yet we are regularly disappointed when it does not. New technological solutions seem to appear daily, and we feel like we are falling behind if we do not jump to join the people who are implementing, selling, or imposing new solutions. Often these solutions are offered before the problem is even fully understood, and no assessment has been made to determine if the solution actually helps to solve the challenge identified. With 80% of us now having transitioned to EHRs, we know full well their benefits as well as their pitfalls. While we have mostly accommodated to electronic documentation, we are now at the point where we are beginning to explore some of the most exciting potential benefits of our EHRs – population health, enhanced data on medication adherence, and improved patient communication. As we look at this next stage of growth, we are reminded of a lesson from an old joke:
A rabbi dies and goes to heaven. When he gets there he is given an old robe and a wooden walking stick and is told to get in line to the entrance to heaven. While the rabbi waits in the long line, a taxi driver walks up and is greeted by a group of angels blowing their horns announcing his arrival. One of the angels walks over to the driver and gives him a flowing white satin robe and a golden walking stick. Another angel then escorts him to the front of the line.
The angel turned toward him, smiled, and shook his head. “Yes, yes,” the angel replied, “We know all that. But, here in heaven we care about results, not intent. While you gave your sermons, people slept. When the cab driver drove, people prayed.”
As we look ahead to the next generation of electronic health records, there are going to be many creative ideas of how to use them to help patients improve their health and take care of their diseases. One of the more notable new technologies over the last 5 years is the development of wearable health devices. Innovations like the Apple Watch, Fitbit, and other wearables allow us to track our activity and diet, and encourage us to behave better. They do this by providing constant feedback on how we are doing, and they offer the ability to use social groups to encourage sustained behavioral change. Some devices tell us regularly how far we have walked while others let us know when we have been sitting too long. As we input information about diet, the devices and their associated apps give us feedback on how we are adhering to our dietary goals. Some even allow data to be funneled into the EHR so that physicians can review the behavioral changes and track patient progress. The challenge that arises is that the technology itself is so fascinating and so filled with promise that it is easy to forget what is most important: ensuring it works not just to keep us engaged and busy but also to help us accomplish the real goals we have defined for its use.
Wearable technology is now the most recent and dramatic example of how the excitement over technology may be outpacing its utility. Most of us have tried (or have patients, friends and family who have tried) wearable technology solutions to track and encourage behavioral change. A recent article published in JAMA looked at more than 400 individuals randomized to a standard behavioral weight-loss intervention vs. a technology-enhanced weight loss intervention using a wearable device over 24 months. It was fairly obvious that the group with the wearable device would do better, and have improved fitness and more weight loss. It was obvious … except that is not what happened. Both groups improved equally in fitness, and the standard intervention group lost significantly more weight over 24 months than did the wearable technology group.
There are many reasons that this might have happened. It may be that the idea of this quick feedback loop is in itself flawed, or it may be that the devices and/or the dietary input is simply imprecise, causing people to think that they are doing better than they really are (and then modifying their behavior in the wrong direction). Whatever the explanation, seeing those results, I think again of the moral handed down though generations by that old joke – that here on earth we need to care less about intent and more about results.
Reference
Jakicic JM, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss The IDEA Randomized Clinical Trial. JAMA. 2016;316[11]:1161-71. doi: 10.1001/jama.2016.12858
Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
We live inundated with promises that technology will solve our most challenging problems, yet we are regularly disappointed when it does not. New technological solutions seem to appear daily, and we feel like we are falling behind if we do not jump to join the people who are implementing, selling, or imposing new solutions. Often these solutions are offered before the problem is even fully understood, and no assessment has been made to determine if the solution actually helps to solve the challenge identified. With 80% of us now having transitioned to EHRs, we know full well their benefits as well as their pitfalls. While we have mostly accommodated to electronic documentation, we are now at the point where we are beginning to explore some of the most exciting potential benefits of our EHRs – population health, enhanced data on medication adherence, and improved patient communication. As we look at this next stage of growth, we are reminded of a lesson from an old joke:
A rabbi dies and goes to heaven. When he gets there he is given an old robe and a wooden walking stick and is told to get in line to the entrance to heaven. While the rabbi waits in the long line, a taxi driver walks up and is greeted by a group of angels blowing their horns announcing his arrival. One of the angels walks over to the driver and gives him a flowing white satin robe and a golden walking stick. Another angel then escorts him to the front of the line.
The angel turned toward him, smiled, and shook his head. “Yes, yes,” the angel replied, “We know all that. But, here in heaven we care about results, not intent. While you gave your sermons, people slept. When the cab driver drove, people prayed.”
As we look ahead to the next generation of electronic health records, there are going to be many creative ideas of how to use them to help patients improve their health and take care of their diseases. One of the more notable new technologies over the last 5 years is the development of wearable health devices. Innovations like the Apple Watch, Fitbit, and other wearables allow us to track our activity and diet, and encourage us to behave better. They do this by providing constant feedback on how we are doing, and they offer the ability to use social groups to encourage sustained behavioral change. Some devices tell us regularly how far we have walked while others let us know when we have been sitting too long. As we input information about diet, the devices and their associated apps give us feedback on how we are adhering to our dietary goals. Some even allow data to be funneled into the EHR so that physicians can review the behavioral changes and track patient progress. The challenge that arises is that the technology itself is so fascinating and so filled with promise that it is easy to forget what is most important: ensuring it works not just to keep us engaged and busy but also to help us accomplish the real goals we have defined for its use.
Wearable technology is now the most recent and dramatic example of how the excitement over technology may be outpacing its utility. Most of us have tried (or have patients, friends and family who have tried) wearable technology solutions to track and encourage behavioral change. A recent article published in JAMA looked at more than 400 individuals randomized to a standard behavioral weight-loss intervention vs. a technology-enhanced weight loss intervention using a wearable device over 24 months. It was fairly obvious that the group with the wearable device would do better, and have improved fitness and more weight loss. It was obvious … except that is not what happened. Both groups improved equally in fitness, and the standard intervention group lost significantly more weight over 24 months than did the wearable technology group.
There are many reasons that this might have happened. It may be that the idea of this quick feedback loop is in itself flawed, or it may be that the devices and/or the dietary input is simply imprecise, causing people to think that they are doing better than they really are (and then modifying their behavior in the wrong direction). Whatever the explanation, seeing those results, I think again of the moral handed down though generations by that old joke – that here on earth we need to care less about intent and more about results.
Reference
Jakicic JM, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss The IDEA Randomized Clinical Trial. JAMA. 2016;316[11]:1161-71. doi: 10.1001/jama.2016.12858
Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
We live inundated with promises that technology will solve our most challenging problems, yet we are regularly disappointed when it does not. New technological solutions seem to appear daily, and we feel like we are falling behind if we do not jump to join the people who are implementing, selling, or imposing new solutions. Often these solutions are offered before the problem is even fully understood, and no assessment has been made to determine if the solution actually helps to solve the challenge identified. With 80% of us now having transitioned to EHRs, we know full well their benefits as well as their pitfalls. While we have mostly accommodated to electronic documentation, we are now at the point where we are beginning to explore some of the most exciting potential benefits of our EHRs – population health, enhanced data on medication adherence, and improved patient communication. As we look at this next stage of growth, we are reminded of a lesson from an old joke:
A rabbi dies and goes to heaven. When he gets there he is given an old robe and a wooden walking stick and is told to get in line to the entrance to heaven. While the rabbi waits in the long line, a taxi driver walks up and is greeted by a group of angels blowing their horns announcing his arrival. One of the angels walks over to the driver and gives him a flowing white satin robe and a golden walking stick. Another angel then escorts him to the front of the line.
The angel turned toward him, smiled, and shook his head. “Yes, yes,” the angel replied, “We know all that. But, here in heaven we care about results, not intent. While you gave your sermons, people slept. When the cab driver drove, people prayed.”
As we look ahead to the next generation of electronic health records, there are going to be many creative ideas of how to use them to help patients improve their health and take care of their diseases. One of the more notable new technologies over the last 5 years is the development of wearable health devices. Innovations like the Apple Watch, Fitbit, and other wearables allow us to track our activity and diet, and encourage us to behave better. They do this by providing constant feedback on how we are doing, and they offer the ability to use social groups to encourage sustained behavioral change. Some devices tell us regularly how far we have walked while others let us know when we have been sitting too long. As we input information about diet, the devices and their associated apps give us feedback on how we are adhering to our dietary goals. Some even allow data to be funneled into the EHR so that physicians can review the behavioral changes and track patient progress. The challenge that arises is that the technology itself is so fascinating and so filled with promise that it is easy to forget what is most important: ensuring it works not just to keep us engaged and busy but also to help us accomplish the real goals we have defined for its use.
Wearable technology is now the most recent and dramatic example of how the excitement over technology may be outpacing its utility. Most of us have tried (or have patients, friends and family who have tried) wearable technology solutions to track and encourage behavioral change. A recent article published in JAMA looked at more than 400 individuals randomized to a standard behavioral weight-loss intervention vs. a technology-enhanced weight loss intervention using a wearable device over 24 months. It was fairly obvious that the group with the wearable device would do better, and have improved fitness and more weight loss. It was obvious … except that is not what happened. Both groups improved equally in fitness, and the standard intervention group lost significantly more weight over 24 months than did the wearable technology group.
There are many reasons that this might have happened. It may be that the idea of this quick feedback loop is in itself flawed, or it may be that the devices and/or the dietary input is simply imprecise, causing people to think that they are doing better than they really are (and then modifying their behavior in the wrong direction). Whatever the explanation, seeing those results, I think again of the moral handed down though generations by that old joke – that here on earth we need to care less about intent and more about results.
Reference
Jakicic JM, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss The IDEA Randomized Clinical Trial. JAMA. 2016;316[11]:1161-71. doi: 10.1001/jama.2016.12858
Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
The EHR Report: Seeing through a glass, darkly
Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.
Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.
This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.
We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:
“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”
Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.
Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.
Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.
This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.
We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:
“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”
Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.
Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
Recently, we were invited to take part in an case presentation focused on a young female patient. The reason for our specific invitation was because a key component in the patient’s case was centered on her electronic health record. This kind of story was not new to us – in fact, stories like these are becoming almost common everywhere. But this particular conference promised to be very special, because the patient herself was asked to take an active role and present the story from a unique perspective – her own.
Seated on stage in a hospital gown and accompanied by her I.V. pole, the patient related a 4-month history of symptoms. She had obviously told the story dozens of times – through seemingly endless encounters – to her primary physician, hospital residents, medical students, emergency physicians, and just about anyone else who would lend an ear. Listening to her share her story with a large audience while still a patient in the hospital was incredibly powerful; it was difficult not to become emotional with her as she welled up with tears. She told a complex, though very coherent tale that included her past medical and family histories, her employment, her hobbies, and her unusual signs and symptoms as they developed over an extended period of time. When the patient was done, her case was presented from another perspective: the way it was recorded in her electronic record. For a brief moment, those seated in the audience were confused. Then the theme of the conference became evident – these were completely different stories.
This was no case of mistaken identity or registration error. The chart presented at the conference did belong to the patient, but the story told by the chart was wrong. Reading through the chart, it would be easy to come away with the same sense as her care team; this must simply be a common illness that wasn’t responding to conventional treatment. Encounter after encounter, a new plan was devised to address the presumed diagnosis. But the patient’s telling of the history barely mentioned any symptoms related to that diagnosis. Her version focused more on how her life was affected, how she could no longer take care of her daughter, how she could no longer exercise (which she did avidly), and how she was sinking deeper into despair and losing hope. Woven through all of this were the historical details and seemingly obvious physical manifestations that might easily disclose the real cause of her symptoms. A few basic questions about her family history would also reveal multiple immediate family members who suffered from the same disease! But even if these questions had been asked, and even if the story had been heard, the image in the mirror – her chart – did not reflect an accurate understanding of the patient.
We often solicit comments from readers, and the response is alway encouraging. It is clear that our colleagues in the medical community feel a strong sense of obligation to their patients and care deeply for maintaining the sanctity of the physician-patient relationship. However, many feel the electronic health record has become a barrier to developing and nurturing that relationship, standing in the way understanding their stories. One poignant letter from a cardiologist in Florida, Eugene H. Eisman, MD, does a beautiful job in crystallizing this sentiment. Dr. Eisman writes:
“Many of my patients end up hospitalized where I do not have privileges. Almost every attending is attentive enough to send me a discharge summary. These, however, are EHR-generated. The patient may have been hospitalized for 3 days, yet the summary is seven pages long. It is filled with total nonsense, such as whether the patient had traveled to North Africa (even though he was hospitalized with a fractured hip while skiing in Colorado). The attending has managed to cut and paste reports of every chest film and CBC, and I have pages of normal studies. The final diagnosis and discharge medications are difficult to find in this morass of words. I cannot force myself to read this document, and it is thrown into his chart after a cursory glance. Yet, I can’t sleep at night. Is there buried in this seven-page document a discovery of malignancy, etc.?”
Dr. Eisman’s words are powerful because they reveal an oft-overlooked truth about modern medical records. The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient, no matter how mundane or trivial. No thought need be put into preserving the important details, because now absolutely every detail can be included. We have become so overloaded with the unimportant, that we may lose the truly critical in this sea of information. It has become, therefore, imperative that physicians rediscover the patient in their story, and not rely solely on the poor reflection we may find in their chart.
Thousands of years ago, the apostle Paul wrote that “we see now as through a glass, darkly.” Borrowing from his original meaning, these ancient words have been quoted throughout literature to describe an “incomplete understanding,” often mixed with a state of despair. Today, we might think of the electronic record as the glass – or mirror – reflecting the patient’s story. Ironically, in spite of having more information than ever, the image we see may be incomplete, and possibly even wrong altogether. While the amount of available data may at first glance appear enlightening, the reflection in the glass may be rather dark indeed.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care. Neil Skolnik, MD, is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.
