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Tablets going away in the future?

Recently, I was contacted by a reader who attended the recent Startup Weekend in Madison.  He asked me about my thoughts on using tablet computers to work with an EMR system.

I told him that, although it is possible to work with our EMR via tablet, I usually use a PC desktop machine, which I find much more versatile.  I like the concept of a tablet, but it really is more of a visual statement/wow factor (think Star Trek) for patients to see a doctor using rather than necessary.  I think it might be more important if I were walking around a hospital from room to room, or moving from room to room to see patients.  However, my workflow model includes a brief exam with each patient at the beginning of our encounter and then moving quickly from the exam room to my office for across-the-desk counseling and discussion.  It works well this way and appears more professional in my opinion (rather than doing everything in the exam room and then ending the encounter.)

My further thoughts on tablets are that they may be a passing fad, especially now that Apple has introduced lightweight “Air” laptops.  In reality, I have both an iPad-2 and an iPad-Mini that, for the most part, sit in a drawer unused.  I do almost everything in my life on an iPhone, my Macbook Air, my office PC, and my home PC.  Tablets do not play a major role.  I think the necessity of a good physically distinct keyboard is so natural and intuitive that this essentially makes tablets less attractive.  The only thing that makes a tablet more attractive, which I predict will be included in laptops in the future, is standalone cellular service that obviates the need for wi-fi or hardwire connectivity.

April 7, 2014 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

EMRs costly to health system

A recent New York Times article caught my eye the other day.  The author focused on the seeming corruption of physicians bilking patients out of tons of money for unnecessary procedures and the havoc wreaked on the American public as we try to keep the rising costs of healthcare down.

The most interesting part of the piece was the amount of blame placed on doctors as the culprits (which in the extreme examples cited was probably warranted).  Of course, as an industry insider, I can tell you that there was so much under the surface that the writer either failed to comprehend, did not know about, or simply chose to ignore.  Judging by the comments from medical providers, I wasn’t alone in my thinking.

Although not her fault, the author bought into MGMA data that was grossly wrong, for example.  I can’t imaging too many dermatologists making just $175,000 annually in 1995.  From a wasted $800 fee that my clinic had to pay to gain access to a data set when we tried to offer a competitive salary to an endocrinologist in our clinic in 2011, I can tell anyone that the data we viewed grossly overestimated the average endocrinologist salary.  The MGMA data we bought was based on only 15 doctors in only 5 practices in the entire mid-Atlantic region who were apparently making an average of over $300,000 annually.  A Medscape survey quoted a more believable $168,000 annually for an endocrinologist.

I have to apologize for the rather longwinded intro to my EMR thought of the day, which is the cost of EMRs to the healthcare system in America. It seems that not too long ago it was much cheaper to use paper charts. Currently, most EMR systems are simply expensive recording tools. Some of them don’t even really generate insightful or easy to read medical notes, although what they do produce may be argued by some EMR vendor companies and end users to be some form of documentation that loosely qualifies for generating a bill for an office note or medical procedure (wide spectrum of quality here).

Some EMR systems are free but most are costly, either lump sum up front with ongoing annual maintenance fees, or pay-as-you-go monthly rentals of depository databases where data from medical notes is stored. Why is the medical establishment wasting all of this money when research has shown again and again that EMR systems do not produce more safety or efficiency of providing healthcare for anyone?

With incentive programs from the US government driving and pushing doctors to set up their own EMR systems for the past 4-5 years, unfortunately, this has been a horribly misguided, misplanned, and costly experiment by probably well meaning individuals who found it un-PC to admit their mistakes. Personally, I wish the government had stayed out of it and let the market forces do what they do best, provide cheaper and cheaper hardware and software options over time until the value of EMR systems eventually sunk or swam the market on their own.

I personally use a free version of an EMR system, which works fairly well (with various glitches here and there during periodic system upgrades). However, I am in the minority since most of my colleagues in the Washington, DC area are either still working on paper charts or have shelled out gazoomba bucks to use a costly EMR system. I am willing to wager that the DC market is not too different from everywhere else in America in that respect. Although I love my EMR system for its organization and ability to electronically prescribe medications with a few clicks of the mouse, I think it remains equally important to consider that the EMR experiment in America is largely failed to produce any significant tangible results and only costs the entire system more, which in the end will be passed on to the consumer.

No EMR system makes doctors more money. The carrot and stick incentive model that the U.S. government used to promote EMR use is small and will be short lived. With ongoing EMR costs to medical providers, this technology has already begun placing another money suck on the healthcare system. Paper and ink are far cheaper by simple math. The only way it makes fiscal sense to continue the EMR market as a cost saving measure is to make all EMR systems of zero cost to the medical providers who use them, which will probably never happen. This is the only way that additional costs cannot be passed on to patients (cleverly couched, of course by well meaning doctors who need to keep their own costs down). Challenging as it may seem, I am hoping that someday someone can think of a positive solution to this important problem.

January 21, 2014 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Sandals, the Middle East and electronic medical records — symbols of partnership

Sandals… what a powerful symbol for today’s blog post.  Apolis Middle East Project is an interesting short film that documents the partnership for business purposes of two groups of workers on each side the Israeli-Palestinian divide.  The product that these sides are working together to bring to market is, simply, sandals.  As in, basic footwear thousands of years old in concept.  The oldest known sandals were found in Fort Rock Cave in Oregon, about 10,000 years old.

On the surface, the short film seems to have a quaint, gee-whiz, aww-shucks, can’t-we-all-just-get-along feel.  However, it reminded me of the partnership between doctors and the software vendor companies that make electronic medical records. One group can’t be successful without the cooperation of the other group.

Doctors need EMR vendors to provide a useful and user-friendly product that will help document the healthcare and decisionmaking of doctors. EMR vendors need doctors to bring life and usefulness to their product. But when the partnership happens, modern healthcare that affects millions of lives for the better is allowed to unfold.

A popular view of electronic medical records by doctors is one of just another thing getting in the way of good healthcare because they take additional time and training to use well. But when you think about it, this partnership is really very important if we want to make the world a better, safer place for us all to live and share.  EMR vendors make it possible for doctors to touch patients lives in a safe and well documented way.  Doctors provide healthcare to all, bringing the impact of EMR vendors to millions of patients every day, including even the EMR vendors themselves.  :-)

January 11, 2014 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Electronic medical records with community health and the environment in mind

My thought for today focuses on how using electronic medical records helps us maintain the health of our communities by keeping the environment in mind, which ultimately promotes health for all.  Contrary to what some might think, you don’t have to write a prescription or perform a medical procedure to help keep patients healthy.

I recently stumbled upon a thought-provoking company, Toms Marketplace.  Toms purports itself to be “a different way to shop”.  Established just recently in 2013, Toms’ great philosophy is to use profits from the sale of their community-centered products to give back to local communities in multiple ways.  For example, some of their toy sales support reforestation.

On a deeper level, aren’t we getting at some of the same grassroots issues by voluntarily using EMR systems that attempt, in their purest form, to be paperless?  Yes, EMRs can save trees and the environment in Honduras and elsewhere, and that has to be a good thing.

Trees should be a priority.  They are objects of beauty.  They provide oxygen for us to breath.  They provide shade on a hot day, which, depending on where you are in the world, can even save lives.  They help reduce atmospheric carbon dioxide and thus reduce global warming (yes, it probably does exist!) and all of its associated problems.  We are no longer living in the world of 1000 AD, and if people continue to use the world’s natural resources with abandon, then there can be consequences.

Thus, EMR users should revel and keep in mind a simple fact — that simply by getting away from the use of paper charts, they are touching the world for the better every day … keystroke by keystroke … tree by tree … and life by life.

child tree

January 5, 2014 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Reinventing the EMR wheel

Going to dictate this one.  I’m really trying hard lately to get back into the blogging mode, although it’s been a busy year, I’ll have to admit.  From bringing on a fourth provider to running through staffing problems in the middle of the summer to saving enough money for a second unbelievable expansion of our office slated for April 2014, it’s been a whirlwind!

Finally had some time this weekend to take a breather, though.  It seems I’m always reinventing the wheel on how to run a completely efficient practice and get everything done while making it all look too easy.  Let me be honest, making it look easy usually includes a lot of late nights and weekends hours.  It ain’t all glamor, ha!  But for the past two weeks, I’ve been able to get all my charting and nurse practitioner notes supervised, edited, tied with a bow, and delivered/signed off on, by Friday at 5 PM.  All while seeing 20 patients that day myself!  (Thank God she’s off on Friday.)

What does this have to do with electronic medical records? Actually a lot. Pretty much everything I do on a daily basis requires my electronic medical record.  I’m pretty much glued to it.  The most interesting part has been the number of times over the past few years, since opening our practice, that I have been able to get everything done in the week by Friday at 5 PM, only to be knocked off my king-of-the-hill position when adding a new complexity to my business.

I love it when I meet an entrepreneur out within their first year of owning and running a business.  We went to a lovely spice market this weekend in the union market in DC.  Bazaar Spices is a great little start up.  You should check them out if you have a chance.  A nice lady and her husband started this enterprise nine months ago and they have quite a nice selection.

Hearing her speak reminded me about all that we have gone through in our own business over the last three and half years (four years in December!  Yeah!).  I recall another fellow doctor who opened his practice in DC in primary care about 15 years ago, and he says that every year is a new set of lessons to be learned.   It never gets easier.  Apparently, there is no resting on your laurels in this business.

My piece of advice for this blog post for any doctors or other providers out there using electronic medical records is to figure out what would you rather do the least on the weekends, and then do this during the week.  Plan for some rejuggling of priorities as you bring on new providers and additional tasks into your workflow.  Then save the easy stuff for the weekends if you have to.  Usually it flies by and your personal life comes back faster.

September 16, 2013 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

EMRs Can Enhance Patient Engagement

The following is a guest post by Scott Zimmerman, President of TeleVox Software, Inc, whose bio appears below.

It’s well known that when EMRs are partnered with patient engagement technology, physicians can communicate more effectively and tailor their treatment plans to meet the needs of their patients.  For example, a patient who has diabetes can receive communications about monitoring blood sugar, while a patient who has high blood pressure can get daily reminders to exercise and take their medication.  This type of engagement can be highly beneficial, as TeleVox Healthy World research found that 83 percent of people across the nation admit they don’t follow treatment plans exactly as prescribed.

Though the use of EMRs is still debated among medical professionals, research has suggested that by transcending the in-office visit using digital technology to communicate with patients on a more regular basis, doctors may finally begin to achieve the amount of communication their patients desire.  It has been estimated that three in ten U.S. consumers would trust their provider more if they received text messages, voicemails or emails that provide patient care between visits.  Of the 66 percent of Americans who have received a voicemail, text or email from a healthcare provider, many report a variety of positive outcomes:

Fifty-one percent reported feeling more valued as a patient.
Thirty-five percent said digital communication improved their opinion of their provider.
Thirty-four percent reported feeling more certain about visiting that healthcare provider again.

When asked about how they felt about office visits in a virtual setting, an astounding 85 percent of patients in a study responded that communications such as email, text messages and voicemails are as helpful, if not even more helpful, than in-person or phone conversations with their healthcare provider.  And when it comes to patients giving consistent full disclosure when communicating digitally, TeleVox’s research showed the following:

Thirty-four percent of U.S. consumers said they would be more honest when talking about their medical needs through an automated call, email or text message than in person with a healthcare provider.
Twenty-eight percent said they would talk more frankly about nutritional habits.
Twenty-seven percent said they would be more open to discussing their fitness regimen.
Eighteen percent said they would talk more freely about their bad habits or personal vices through digital communication rather than in-person visits.

When healthcare providers link EMRs with notifications technology, engaging patients between visits becomes as easy as writing a prescription.  Physicians can use both to create and nurture that personal, human touch during the treatment process.

Scott Zimmerman is a regularly-published thought leader on engaging patients via ongoing communication between office visits. He is the President of TeleVox Software, Inc, a high-tech Engagement Communications company that provides automated voice, email, SMS and web solutions that activate positive patient behaviors by applying technology to deliver a human touch. Scott spearheads TeleVox’s Healthy World initiative, a program that leverages ethnographic research to uncover, understand and interpret both patient and provider points of view with the end goal of creating a healthy world–one person at a time. Zimmerman possesses 20 years of proven performance in the healthcare industry, with domain knowledge in the surgical, interventional and pharmaceutical arenas. Prior to joining TeleVox, Scott served for nine years at GE Healthcare in a variety of cross-functional and global leadership roles in sales, services, quality, marketing, pricing, finance and product development. Scott is a graduate of the John M. Olin School of Business at Washington University in St. Louis.
June 28, 2013 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Why I will never buy another computer… I think

Few things come along that can change the way I “compute”, if you can call it that anymore.

However, during the past Memorial Day weekend, I bought a small Logitech keyboard to go with my iPad mini and have been loving every minute of using it.  The problem I formerly had of needing a WiFi connection for using my Macbook Air on the road is no longer.  Forget hotspotting even.  This keyboard lets me turn my iPad into a true computer with a physical keyboard that is off-screen.

It can go on the road in my backpack or stay at home on my desktop.  I can send print jobs wirelessly to a nearby printer if needed.  What’s more, I now have a touchscreen monitor by the nature of what an iPad is.  If I didn’t have a cable, internet, phone bundle at home ripping me off already, I could get by just fine with going back to just a cellular contract, since the data/internet all comes through my iPhone account with AT&T now.

Even as I wrote much of this blog entry, riding in a car down a country road in upstate New York, it’s as easy as pie.  I would encourage more providers and anyone else out there to make life simpler and get a portable keyboard for their iPad.  The Logitech one is nice and fits the iPad mini well.  It even folds shut, making the bundle slim and sleek, able to slip into a backpack or briefcase in a snap.  And it weighs little more than the iPad itself.

I don’t think I would need a computer again.  My iPad IS my computer now.  I’m sure this sounds like old news to some, but it finally hit me.

image

June 2, 2013 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

The Ethics of Service Outages in Electronic Medical Records

I love my electronic medical record. Life is very different and much more appreciated in the digital, uber-organized, instantly available, anywhere, anytime world of EMRs. Thank the heavens that they are here to save us, both healthcare providers and patients.

However, my particular EMR system has gone out of service twice in the past two months, much to my disappointment. Both times were for, it seems, less than an hour, but extremely painful to live through.  Moreover, since there have been multiple service outages over the past few years, I have gotten more accustomed to the emergency changes that our office needs to take immediately the moment we discover an outage and patients continue to roll in for their visits.

However, it still makes me wonder what ethics might be involved here. On the one hand, occasionally every service might be expected to have outages. Power, water, mail, etc.  Few if any of these services need to run in real time continuously for the protection of people’s lives. However, medical records systems really should run or be available continuously because of the need to make, in real time, medical judgements and plans that affect peoples’ lives.  There is a real problem when medical records are suddenly inaccessible during meetings between healthcare providers and patients.  Obviously, there are differences in the liabilities depending on setting of patients in hospitals and those in outpatient office practices.

I am not a computer programmer and don’t know the possibilities for obtaining backup records immediately (or if this is even possible) when an EMR service fails.  One would think that a backup server/service could be activated, but in our periodic transient cases we have found that this has never happened.  Nothing really “kicks in”.  We simply wait for service to be restored and in the meantime start searching for lab results through our online access to major commercial lab suppliers (i.e. LabCorp, Quest).

Unfortunately, I do not know the solution to this problem, although it seems to be an issue of product development.  In the past it has occurred when new versions of the software were upgraded, but this has not been the case in every instance that we have experienced.  Currently, there are no regulatory agencies that seem to have jurisdiction to police  real-time backup safety requirements for an EMR system, which leaves a big hole regarding liability and responsibility.

I have to wonder how often this occurs for other EMR systems?

April 29, 2013 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

EMRs’ Slippery Slope of Cloning Notes

Given all of the recent hubbub regarding cloning of medical office notes using electronic medical records systems, I thought I would write in with my opinion on this topic. You know, just as one fabulous new technology comes about that enables much more efficient documentation of patient encounters in physicians offices, it seems like critics are quick to try to take away that ability from doctors. Most doctors work hard at what they do and are just trying to do a good job in providing the best of care using all the modern digital tools available.

Since there are no official published guidelines in this area, it seems yet another of many many MANY (did I mention many?) gray zones in the world of digital and mobile health technology.

Like it or not folks, the cut-and-paste function available on any computer is here to stay. It’s up to physicians and other providers like nurse practitioners and physician assistants to choose to use this technology responsibly. Furthermore, I believe that it is not impossible to do so. That would only be logical. Otherwise, we could never acquire anything that made our lives as providers a little easier.

I understand that the Medicare system is practically bankrupt as it is and seeks to minimize fraudulent payouts. I also recognize that there are nefarious individuals out there posing as medical providers who can crank out EMR notes that are identical in a mass-production fashion in order to financially rob the system again and again.

However, let’s not take an anti-EMR philosophy.  Let’s not throw the baby out with the bathwater.  I don’t have the perfect solution, but rather then forbidding medical providers to use the technology in a powerful way to see more patients with less busywork at the end of the day that does not benefit patients whatsoever, I think we need to put more thought into solving this problem. What do they expect doctors to do with EMRs anyway?  Write everything from scratch every time?  Such an approach would be both nonsensical and naive.  And the solution should not be to withdraw the technology or force doctors to do things that are unconventional.

On the contrary, we need guidelines that make sense and do not add needless work to already harried medical professionals.  We need simplicity and not complexity.  We should not seek to recreate the debacle that some people came up with long ago that is the tax code-like nightmare of Evaluation & Management (E&M) guidelines, which are still quite gray in many areas.  We need to be able to empower doctors, NP’s and PAs even further with technology rather than retract abilities that the technology enables.

I’m purposefully not getting into specific examples in this post for the sake of brevity.  But I’ll be happy to take any questions my readers may have.  Who knows, it could lead to interesting future discussions.  For example, the precise definition of “cloning notes”, what qualifies?

November 10, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

EMR use improves primary care: new study

There seems to be a lot of buzz in the news lately around the question of whether electronic medical record documentation can lead to a higher quality of care.  Last year, a study came out suggesting that this might be true for diabetes care.  More recently, my attention came to an article published in the Journal of the American medical informatics Association in May 2012, Method of electronic health record documentation and quality of primary care.

A group of researchers led by Dr. Jeffrey Linder at Harvard University’s Brigham and Women’s Hospital studied primary care physicians taking care of 7000 patients with coronary artery disease and diabetes over nine months. The study authors assessed 15 quality measures, three of which were found to be performed significantly less by physicians using a typical dictation system for record-keeping as opposed to those keeping records by electronic medical records systems.  Two of the three standards of care measures that dictating physicians were less likely to provide were tobacco use documentation and diabetic eye examinations.
This parallels my own findings as an endocrinologist using electronic medical records. During the period of my early years before I instituted widespread use of templating, I was much less likely to hit all of the quality care measure marks compared with after instituting templates.  It’s actually quite commonsensical that a medical provider can hit all of the marks if they are prompted by the computer.  In a sense, the care goes on autopilot.  No matter how chaotic a given point in the day of a busy doctor might be, it becomes impossible to complete a note without performing all of the prompts unless doing so deliberately.

There has been at least one or two studies that I’m aware of that have doubted or not found the conclusion that electronic medical records improve the quality of care patients receive.  I think that most likely these studies did not find a significant association because they were not properly designed.  When one considers the volume of quality measures pertinent to a typical patient visit with diabetes or coronary artery disease, there are so many measures that unless every physician has the measures memorized and never forgets anything, gets flustered or has to hurry through the visit, there will almost be a guarantee that not all measures will be addressed at a visit.  I’ll take that bet and win every time.

The fact that there are now at least two studies showing a positive relationship between the quality of care given to diabetic patients in the use of electronic medical records documentation is even stronger evidence that this is a real phenomenon.  Personally, I can’t believe that anybody would think that electronic medical records don’t lead to better care, regardless of the degree of such improvement.  That is, unless they’re not using the templating advantage.

October 21, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.