Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Get all the latest EMR updates from a practicing doctor for FREE!

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.

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.

FCC highlights ONC Office for Consumer e-Health plans for 2014

One of the things I would like to get back in the habit of in the new year is to contribute more again to this blog, which I started in 2009 with help from John Lynn at Healthcarescene.com.  Part of the challenge of keeping an ongoing stream of thoughts here has been both my busy life as an active provider of subspecialty healthcare, the growth of my practice as a business, and most importantly the emergence of new ideas for consideration and writing.

Luckily, I have been able to find some novel sources recently, and so I am going to try to reach out to these resources more often to gain insight and ideas for new and interesting topics on which to blog.

One of these sources recently highlighted an interview with Lygeia Ricciardi, the ONC Director of Consumer eHealth.  The ONC is under the purview of the Department of Health and Human Services.  Ms. Ricciardi recently attended the FCC’s mHealth Innovation Expo in Washington, DC, on 12/6/13.  She highlighted work on policies for mobile health apps and cited a goal of helping to reach everyday people and empower them to improve their ability to participate in their own healthcare.

M-health apps are currently under voluntary control in whether or not their developers follow ONC guideines for design. Such apps may help patients, who are now often referred to as “consumers”, in such tasks as shopping for good-quality healthy food and reading nutrition labels.  In 2014, the ONC Office of Consumer e-Health plans to launch a website for helping patients find where to gain access to their own health data online.  Such information can include medication lists, laboratory reports, and other records.  Ms. Ricciardi likens this initiative to the “Blue Button” project that targets making medical data available to veterans at VA hospitals.

Access remains a key concern since once patient data is downloaded through a third-party app, such data will then by definition not be protected under HIPAA.  A third-party app developer will automatically gain access to this data during the process.

Ms. Ricciardi also cited possible other uses for mHealth apps, including helping people make participating in the healthcare both fun and interactive.  Examples were provided of apps that can help patients play games to compete against each other to see who can follow healthy habits better, e.g. who can exercise more, check blood pressure more, lose more weight, and check their blood sugars more often (for diabetic patients).  She further stated that consumers are being brought into the ONC process for m-health app policy development on a regular basis to ensure that there is some public guidance for what is and is not desired.  She cited the new paradigm, often quoted by now, that a cultural shift is changing towards more shared decision making in healthcare and giving more power to patients to participate actively in their healthcare rather than being passive bodies directed by healthcare professionals.

She encouraged individual patients/consumers to get more actively involved in their own healthcare.  According to Ms. Ricciardi, although the current medical environment is still mostly of two separate worlds, with little sharing of medical information between medical practitioners and patients, the coming world of m-health apps promises much potential for changing this.

December 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.

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.

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.

7 Tips to Help Improve EHR Etiquette

It’s been a while since I’ve written, but only because my practice has been booming lately and I’ve barely had a moment to breathe here in DC.  But I’m back now, and for who knows how long given the waves tossing on the sea of digital medical practice!

Patient engagement continues to be one of the most common complaints about EMR software.  There was even a mention of the frustrations in a previous post on Happy EMR Doctor.  Many physicians say that it interferes with patient interactions and that now most of their time is spent looking at a computer monitor and updating charts.  This causes frustration for all parties – patients and physicians – because doctors did not sign up for computer duty when they went to medical school and patients expect a doctor’s full attention during visits.

Software Advice, a website that reviews medical software, launched a survey on how to improve doctor-patient interactions in the EMR era and the results are finally in.  See below for the top seven tips received on maintaining quality relationships:

1. Position your computer between you and the patient:  No brainer here.  Face the patient during interactions.  Take the time to plan where your equipment will go so that this possible.

2. Invest in mobility:  Whether it’s a small rolling desk, small tablets or other lightweight tools, choose equipment that helps you move around.  A laptop may cost an extra buck but can be worth the investment.

3. Delegate as much as possible:  The objective is to interact with the patient as much as possible.  Have staff members enter the medical history, medications, prior procedures, etc. prior to the patient’s visit so you don’t have to during the appointment.

4. Dictate as much as possible:  Talk with the patient while scribes enter the information or use dictation software.  These allow you to focus more on the patient.

5. Ignore the computer when you first enter the room:  Chat with your patient for a few minute before you start recording information in the digital record.

6. Ask about previous complaints:  If the patient information is pre-loaded, look over it before entering the room. If they have open complaints, ask them about the issues to close them out in the emr. This reaffirms to the patient that you care.

7. Finish the chart in the room:  This can help to answer any other questions that might come up so patients feel like they have been listened to.

All in all, EMRs take some getting used to.  Once a physician develops a rhythm with the software, every patient interaction becomes easier.  Focus on the tasks as they come, and remember, practice makes perfect.

March 6, 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.

Meaningful Use Is Not For Specialists

You know, I’ve been thinking a lot about Meaningful Use lately. I previously I’ve had pretty negative opinions of it, and my thoughts seem to be echoed by a lot of doctors currently in practice.

Rob Lamberts, MD, wrote an interesting post titled Ten Ways to Make the EMR Meaningful and Useful. I have to admit, his suggestions made an awful lot of sense. They started me thinking about how useless much of my own documentation is because of its origination in archaic rules for receiving insurance reimbursement money. Unfortunately, it seems that a lot of these rules stem from the medical profession itself rather than have been having been thought of exclusively by insurance moguls. For example, the family history is usually almost entirely irrelevant to what my scope of practice generally entails. The Review of Systems (ROS), which is the part of the exam where we as doctors ask the patient a myriad of questions regarding their symptoms, is typically exhaustive, unproductive and usually despised by most practicing physicians. Patients are generally very forthcoming about any active symptoms that they are currently experiencing, and a few additional questions around their symptoms typically suffices for a doctor’s purposes.

The majority of old medical records that I get from previous practices in which the patient has been involved are usually either illegible, irrelevant, or not directly related to the reason the patient is coming in to see me. If I am seeing them for the same purpose and they are just transferring their care to me, I generally will ask much of the same questions that have been asked before, rendering the review of records of even more limited value.

I think that getting meaningful use out of our own individual records could be greatly helped by an overhaul of the medical profession’s recommendations to insurance companies on the types of information that needs to be included in medical office notes for the purposes of providing excellent healthcare. In the increasingly complex and technologically-advanced society in which we live, information “noise” really should be kept at a minimum, especially in providing appropriate healthcare recommendations to patients. Medical records should not be in a habit of containing information that does not change or impact the medical management of the patient. We really need to revisit the idea of “gee whiz” type of data and cut out any extraneous documentation.

This would, of course, require that meaningful use become much more personalized and individualized to specific doctors and their specialties. The current state of meaningful use is actually fairly limited in that it applies mostly to primary care providers making recommendations for preventive health care. Preventive health care, unfortunately, is almost never the reason why patients seek the advanced medical knowledge of specialists and subspecialists in specific areas of medicine.

In summary, I agree with Dr. Lamberts that we need to overhaul meaningful use into something that is much more meaningful and usable.

October 1, 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.

Patient Engagement: Who are the Real Targets?

As I further considered the ideas generated by the breakfast panel I had the opportunity to participate in recently, Doctors and Patients: Bridging the Digital Divide, I was reminded of a stimulating comment made by Nikolai Kirienko, a patient advocate with Crohn’s disease. He stated that we need to use the current technology to reach patients who need it most.

But who are these patients, really?

Are they the well and well-to-do, middle to upper-class population who are internet-savvy, highly educated, and compliant with following the plans suggested by the healthcare provider?

Are they the patient struggling with chronic illnesses, the symptoms of which may tend to wax and wane on a daily basis, making their issues a daily struggle?

Are they the poverty-stricken residents of typically lower class neighborhoods in metropolitan areas, who may have more limited access to digital technology?

From my personal experience in a downtown metropolitan area, namely Washington, DC, I can tell you that most of the patients who are engaged in seeking out new information regarding their health conditions tend to be highly educated, middle to upper-class patients with excellent access to digital technology.

But I have to come back to the initial comment in question, which begs the question of who should we really be targeting?  Who can really take the most advantage to gain from the digital healthcare revolution?

I could take the Pollyanna-esque view that everyone should be able to take advantage of everything equally and we should all just get along and be happy.  However, real-world experience tells me that there may be a different answer this question.  There are also limited resources for healthcare outreach campaigns.  Therefore, it would seem appropriate to do more research into the area to really define who the best targets are for the maximum benefits. It certainly seems like a valuable question to answer and one that’s worth going after.  What do you think?

September 24, 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.