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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.

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.

Patient engagement in the digital era

In the not-so-old days of medicine, patient engagement used to involve things like looking the patient in the eye when speaking to them, facing the patient, asking them how they felt, and asking them if they had any other questions before ending the visit. These so-called rules of engagement have now been augmented by the computer in between the patient and the provider.

No longer are the former etiquette protocols sufficient for interacting in the digital era. Now, patient engagement includes Internet searches using “Dr. Google” for what in my opinion are typically anxiety-fueled questions that are frequently unnecessary and irrelevant and would not have been asked prior to the arrival of Internet searches.

However, the internet isn’t going anywhere anytime soon, and so providers have to be able to deal with this new level of interaction. Fortunately, not all patient engagement is so maladaptive.

Patient engagement is a funny thing though. It seems to be confused by doctors, staff and patients. Some people think patient engagement involves E-medicine, or rather electronic visits over secure messaging systems. I laughed the other day when I viewed a YouTube video showing a woman talking about a third party for-profit software vendor company using their technology to allow patients to pay bills online and therefore be more” engaged”. Right. That’s twistier than Presidential campaign rhetoric.

Another speaker put it well when he said that “reality struggles to keep up with the rhetoric” when he was commenting on the difficulty in defining patient engagement, yet everyone wants to use the jargon liberally.

I prefer to think of patient engagement in the digital era as being positive in several respects. I expect the patients to take an active role in their healthcare, in gaining knowledge about their disease, and in gaining knowledge about health prevention and treating ongoing illness issues. In doing so, the patient becomes empowered to take an active role in the decision-making process during the testing and treatment phases of care. This is not to say the patient should get to consult Dr. Google and then dictate what tests are being done on them regardless of what the ordering provider thinks is appropriate. I think the most ethical and appropriate response to such requests are to, first, consider them seriously; second, discuss with the patient which tests are medically indicated and which tests are medically unnecessary; and finally, to stand one’s ground in either writing or not writing for any medically unnecessary tests to be ordered.

I also completely agree with the definition of patient engagement as defined by the Society for Participatory Medicine. It says that patient engagement is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.

In order to get patients more engaged in participating in their healthcare, I think we need to make it fun, make it interesting, and communicate using means where the patient actually is, on multiple levels of “is”. In the case of the digitally connected patient, we should be considering communicating using the Internet, smartphones, and mobile devices such as iPads. We need to be able to make this communication valuable to the patient so that they, in turn, want more of it, and so that the movement grows.

September 17, 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.

Can We Talk? Challenges of SaaS Type EMR User Interfaces

Forget about EMR interoperability between doctors’ offices and hospitals for a moment.

One of the recent developments in the ever-expanding SaaS (software as a service) world of electronic medical records must be the challenge of making all the individual software components talk together correctly.

There is (1) the EMR itself, (2) the programming platform/language, and the (3) internet browser.  Forgive the novice in me if I don’t get all my nomenclature correct.  I’m just a doctor.  If one component gets upgraded (and they always do), then the house of cards can come tumbling down in one fell swoop, at least temporarily.  We’ve experienced this recently at our office with our own EMR system and so I have a few thoughts on the matter.

In our office, first it was Firefox stopped working with the EMR.  Then we all switched over to Internet Explorer, which seemed to work for a time, but then that stopped working well and frequently froze up.  Chrome is working for now, but it seems to be only a ticking timebomb before this no longer works.

To make matters more complicated, different browsers have different ways of displaying information bars at the top, sides and bottom of the EMR window, and so some bars can get in the way of viewing different parts of the screen depending on which browser is used.  There are ways around this (conveniently called “workarounds”), but yet again, not so simple or straightforward and thus suboptimal.  I have to admit that it sort of feels like jiggling the handle on an old toilet to get it to stop running.  In other words, yes, you can do it, but, no, it doesn’t feel like it should work that way ideally.

We’ve been given the explanation that Adobe Flash is having problems interacting with the EMR system, or vice versa, since both the EMR and Flash have gone through successive, iterative upgrades to improve and add functionality to both services.  I can totally buy this explanation.  However, at what point will it just get too difficult to keep everything going?  Is it impossible?  Probably not.  But it’s a heck of a pain watching the EMR go through roadblocks as we forge into the future together, as vendor and provider.

This will undoubtedly affect any EMR system that is dependent upon other, third-party software.  It is a common situation that will change over time, and I’m almost certain that this is going to be a challenge, all around, for any EMR system on the market today.  As such is the case, I look forward to the day when it can be solved permanently by adopting a new standard for all platforms.

August 20, 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.

Does Meaningful Use Destroy Doctors’ Skills?

About two weeks ago, I saw a patient who was referred for a new diagnosis of hypocalcemia (low blood calcium levels).  I ran a few additional appropriate lab tests and will be seeing him back this week or next.  This weekend, however, I had some spare time to read back through the sections of two medical textbooks dealing with a more detailed discussion of this issue.

How apropos, I thought, when reading a recent post on the Health Care Blog, titled The Destructiveness of Measures.  This post says such a powerful amount in such a short blog span, that I needed to highlight and share it.  It succinctly describes what the government is currently trying to do to a highly trained labor force who’s best asset is their ability to think about patients with complex medical problems.  Every minute spent filling out online forms to report meaningful use data to the government could be better spent in reviewing and updating their medical knowledge set.  Both tasks focus on patient’s and their medical problems, yet one is a much higher yield for patient care and physicians’ sharpness in providing higher quality care than the other, which could be completed by a person with a high school education.

Let’s not dumb down our physician’s knowledge levels by asking them to complete such inane tasks as generating Meaningful Use data sets.  Are the physicians the right personnel for such a clerical job?  Absolutely not.  Airline pilots can’t maintain their flying skills by running the beverage cart.  Doctors are no different.

July 23, 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.

How an EMR gets in the way of doctor-patient relationships

For all of the glorification of EMRs and EHRs and pushing into the new age of digital healthcare, I thought I would throw in my 2 cents from the dark side of electronic health record keeping.  To be honest, there are a few things that could be greatly improved.

Now, before I get a whole bunch of unsolicited email from EMR vendors out there waiting to pounce on me with sales pitches of how theirs is better and I should give it a try, I should say that I’m very happy with my current EMR system and not looking to switch.

That notwithstanding, there are a few simple concepts that no EMR system to my knowledge has gotten right yet.  It’s even possible that it may be hard to ever get right, and a lot of it has to do with mouse clicks and typing.

During my average day, I feel the need to maintain at least some eye contact with my patients, mostly because I’m a bit uncomfortable with the amount of time I have to spend looking at my computer.  I’m a bit of a slave to the computer system in that sense.  I know I could do all of the documentation after the patient is gone, but I’m afraid of missing something in the documentation.  You could say I could just scratch notes on paper to avoid missing anything, but this is not in keeping with the lofty goal of being paperless, now is it?  Maybe the lofty point is just to eliminate paper charts.  Still, scraps of paper doesn’t really sound modern or safe now, does it?

I also feel a bit uncomfortable giving up my nights and weekends just to “look good” in front of my patients.  A burned out doctor who has no life outside the office to spend with family and friends, and who ultimately quits the profession because of such, is not an ethical thing to expect of physicians, is it?

And so, for now, I do my best to incorporate a bit of eye contact, but still spend time typing away with the patient across my desk watching me and telling me about their issues.

The EMR still requires a lot of additional tasks outside of documentation: electronic prescribing, reviewing messages from staff and performing additional tasks as necessitated by these messages.  And all of these tasks take a considerable amount of time.  Up until now, they have required human intervention to complete, but what about the future?

One of my recent hobbies is reading history texts.  Interestingly, one of the stimuli that encouraged the Europeans to seek an alternative passage to the Far East was the excessive trading fees imposed by transmitting goods through Muslim and African nations.  An alternative route that would allow the elimination of hefty fees and allow them to run their import-export businesses cheaper and more efficiently was the dream.

If we can automate all of the EMR tasks more effectively using a Siri-like voice-activated platform, then medical providers may be able to achieve all of their work during normal business operating hours, face the patients when they speak, and have a better quality of work and home life than their predecessors.  I’d love to be able to tell my computer to send in a scrip refill for thyroid hormone and it would be done, without the need for any other steps or human involvement, but that remains a far off mirage at this point.

The more an EMR can do for me, the more time I can spend in humanistic and meaningful contact with patients.  I dream of actually living the dream but for now live in the reality of a less than perfect world.

July 16, 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.

Patients Want Electronic Health Care Services

Guest Post by Ken Harrington, Practice Manager at The Washington Endocrine Clinic

In my last posting, I explored the idea of whether having access to a patient’s chart and lab work empowered the patient to be more proactive with their healthcare.  In that posting, I remained skeptical as to whether the chart sharing feature in our EMR accomplished this.  In this post, however, I want to continue exploring this feature of chart sharing and what effect it seems to be having on our patient population.

I start by saying that, generally, our patients like the chart sharing feature, regardless of how they use the data.  Initially, we did not use this feature when we adopted our EMR because it was limited in what it could actually share with the patient.  However, as the EMR has developed over time and labs began to be integrated into patient charts, the obvious benefit of this feature became more valuable, if for no other reason than stopping the printing out of labs, using paper and ink, for many of our patients.  Not to mention that the patient could no longer lose said paper and ink lab reports.

On any given day, we enroll about 8-10 patients into the chart sharing feature that will enable them to have access to their chart.  Through this feature they can see previous and upcoming appointment times, a list of prescribed medications, diagnoses, and lab results from lab companies that send back their results as integrated into the EMR.  Interestingly, not one patient so far has declined the invitation to gain access to their medical chart.  At the start, we e-mail all patients a brief overview of what to expect in the enrollment process, what they will find in their chart, and a temporary PIN to allow them to gain initial access.  Only one person has been dissatisfied with the results thus far, and the access was subsequently deactivated at their request.  Whether or not this is empowering the patients to be more proactive with their healthcare, the bottom line is that the patients like it!  In fact, I wish we could give the patient even more access to their chart as many of the uploaded documents that are not integrated into the chart sharing feature.  Interestingly, a recent story explored this over at Fierce Health IT.

One aspect that this shows is that the internet is an integral part of healthcare today.  This is no longer so revolutionary to say in the healthcare industry.  A recent article I read discussing smart phones said that only 20% of the current US population was using a smart phone, but that industry leaders expected this to increase to 80% by the year 2020.  I think the same is true for how patients will use the internet in regards to their healthcare.  As more doctors adopt EMRs for their practices, and as more EMRs allow for chart sharing, more patients will find that they will need access to the internet to gain access to their medical history and records. Many patients are already indicating that they want this access.

The integration of EMRs into our patient’s lives is helping to create a population of patients that understand that one way to be plugged into their doctor’s office is through the internet. We constantly have patients wanting to e-mail our doctor for advice, to report symptoms, or to request test results. It’s baffling that EMR companies have yet to figure out how to form a financially beneficial relationship with the insurance companies to provide better and faster healthcare through the internet. Many businesses and academic institutions have already figured out how to integrate the use of the internet into their business models to achieve efficient and cost-cutting results. From internet-conferencing, to document sharing applications, businesses and schools have embraced the internet with much creativity. This is only just beginning to happen in healthcare – but I believe it is coming.

I know that insurance companies are reluctant to pay for healthcare administered through an internet exchange, and some of those reasons are very good. But imagine this: the integration of Google video chat or Skype with an EMR that will allow for the doctor and patient to login to the same EMR where the patient’s chart is located and have a discussion about lab tests or radiology results. Not all patient-physician interactions include a hands-on physical exam. If the doctor finds something in the results or discussion that warrants a more through physical exam, then one could be set up for the patient at the end of the “e-visit”. Maybe the reason insurance companies are reluctant to pay for healthcare in this way is that they know the patients will embrace the ease of access and begin using the insurance policy more. Hmm… The less people use healthcare access, the more premiums the insurance company gets to keep. But I digress…

The EMR is changing not just the relationship between the physician and patient, but it is changing the patient themself. Patients in our office are slowly becoming used to the integration of electronic medicine. They have learned to expect to find their electronically sent prescriptions waiting for them at their pharmacies, or to find access to their labs, list of medications and upcoming appointment times in their online chart. Patients in our office are slowly being taught to fax their records to the office because our online fax will automatically turn their documents into a PDF file, which can then be uploaded easily to their chart. Patients are learning to expect all bills from our office to be e-mailed to them rather than physically mailed. Patients are learning that during the visit, for the doctor to “look back in the chart at previous notes,” requires waiting for the doctor to click through an electronic record at the computer on the doctor’s desk rather than flip through a paper chart. Some patients are even learning that to have a summary of what the doctor recommended can now be e-mailed to them upon their request.

The patient that is the least frustrated with the technology integrated into the healthcare we provide in our office is the patient who can adapt to this technically changing environment. We certainly have patients who get frustrated adapting or who do not even use e-mail, but these are only a few. Unfortunately, there is no way for patients who cannot adapt to an electronically based medical office to survive in our office. We do not have special paper charts for a few selected group of patients, and our doctor rarely writes paper prescriptions anymore.

Is our office just the sign of the times? Perhaps. But we have found that having an electronically-based medical office is more efficient, cuts down on staff requirements and helps us to compete with a stronger financial footprint in today’s marketplace. We are not turning back in this office, and I’m not sure the majority of our patients want us to. In fact, I think they are waiting for the next level of technical innovation to come out that will enable them to get their healthcare needs taken care of in an even more efficient way.

June 27, 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.

International EMR: The Netherlands

I recently had a few days out of the office and decided to visit Amsterdam.  I had never been there before and thought I would look up what’s been going on in the Netherlands with regards to electronic medical records.  It turns out that approximately 90%+ of Dutch medical doctors are using EMR and EHR systems, according to a Canadian study quoted in Full Electronic Medical Records Still 20 years Away.  In a slightly older post from 2008, Canada Lags in Electronic Medical Records, the number quoted for Netherlands docs was higher, at 98%.

This post struck me as very interesting because of the information regarding just how electronic were medical practices in various countries in Europe.  Not only does it discuss EMRs, but also PDAs and websites of practitioners, which gives the reader a feel for just how technologically savvy various countries’ docs really are.  A listing of sources is at the end to let you know they didn’t just pull the numbers out of the air.

A motherlode of information (Electronic Patient Record in the Netherlands) about the early days of the Dutch EMR experience was presented in 2002 and sounds eerily similar to what we are facing in the U.S. today.  The issues are so similar in some cases that it’s tempting and begs the question to predict what will eventually happen in the U.S.

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 and opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.  Some of his blogs also appear at EHROutlook.com.

October 13, 2011 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.