Electronic Medical Records

flying cadeuciiIn the United States, the question has been asked time and again but never satisfactorily answered. By virtue of publically financed healthcare systems, the rest of the developed world has decided, to a greater or lesser extent, that medicine and healthcare are not pure businesses—that citizens have a right to care, even when they can’t pay all associated costs.

It’s starting to look like Americans won’t be able to duck the question for much longer.

In the last year, the profitability of U.S. hospitals eroded for the first time since the Great Recession, pushing some closer to and others over the solvency precipice. Revenues are down and costs are up.  And these issues appear systemic and entrenched, giving rise to a series of important and relevant questions: How can hospitals adapt?  If they do, will they still survive? And, do we as a nation think it’s important to make hospitals accessible, even if they lose money?

As recently reported in the New York Timesanalysis by Moody’s Investors Service shows that this year nonprofit hospitals had their worst financial performance since the Great Recession. Among the 383 hospitals studied, revenue growth dipped from a 7 percent average to 3.9 percent on declining admissions.  For the last two years, expenses have grown faster than revenues, and fully one quarter of all hospitals are operating at a loss.

In a word, Moody’s describes the situation as “unsustainable” because it is the product of what look like enduring realities:

  1. Private insurers did not increase payments to hospitals.
  2. Medicare reduced payments due to federal budget cuts.
  3. Demand for inpatient services declined as outpatient care options rose.
  4. Retail outpatient options now compete with hospital clinics.
  5. Patients with higher copays and deductibles chose not to seek care.
  6. Hospitals are buying up physician practices.
  7. The costs of electronic medical record systems are impacting the bottom line.

Continue reading “Is Healthcare a Business?”

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EMR adoption is skyrocketing, in no small part due to government incentives. The office of the national coordinator lauds this hockey-stick curve as a success. Advocates promise electronic records will improve patient care, reduce mistakes, and save healthcare costs. At the same time, doctors love to complain about implementation cost and poor usability. How can we reconcile these differing opinions? The truth is they are describing very different technologies. EMRs, the way they are implemented now, will not accomplish these goals. In fact, early adopters can become stuck at a rudimentary level of functionality, and the extensive feature lists described by meaningful use criteria fail to address the most basic needs for patient care.

I have been at medical institutions at different levels of technological development. Each has a different attitude toward the EMR; for some its loathing, others longing. Some devote resources to try to improve it, but others give up. I realized the parallels with Maslow’s Hierarchy of Needs, people are motivated to attain something only after their very basic needs have been fulfilled. So are EMRs good or bad? Well, it depends on where you are on the hierarchy.

The figure above describes the steps to building a technology infrastructure that will lead to improved patient care. Yes, incentives help us achieve some very basic needs, but the problem is that decisions and investments we make now will determine the ceiling as well.

Continue reading “Maslow’s Hierarchy of Health IT”

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In writing about OpenNotes last summer, I argued that the practice of sharing clinicians’ notes with patients had moved beyond the question of whether it was a good idea (the landmark study published in Annals of Internal Medicine was pretty clear on that) to questions of how best to implement it.

As more organizations adopt the practice, it’s clear that we’re now in a phase of implementation, and experimentation with different approaches and learning.  Tom Delbanco, MD, one of the project leads, often compares open notes to a drug — it does have some side effects and some contraindications for some people and some circumstances — and we all need to understand those nuances.

To make it easier for health care organizations to offer the service to their patients, the OpenNotes project team has just released a new toolkit.

The toolkit focuses on two challenges:  helping organizations make the decision to implement open notes and helping organizations with all the steps involved in implementing open notes.

It includes a slide deck that lays out the results of the study and makes the case for implementation, a video profile of how a patient and her doctor have used the practice, profiles of the implementations at the pioneering sites, FAQs for clinicians and patients, and tips for clinicians on how to write open notes.

Please check it out and tell the OpenNotes team what you think:  is it valuable? How could it be better?

Continue reading “The OpenNotes Toolkit”

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One of the spinoffs of being an oncologist is that you do not to take the world for granted.  Each morning, I walk around the yard and smell the morning breeze. I am thankful for my children, my wife and my own health.  I am thrilled, if occasionally skeptical, to have the opportunity to pay taxes in a Country that I love.

So, who would believe I would take our Electronic Medical Record (EMR) for granted?

I know, shocking, isn’t it?  How could I overlook a key factor in the success of our practice, ever since we ditched paper records, 13 years ago? Nevertheless, it is true. Day-by-day, the keyboard and screen became just another device, like a stapler, paintbrush or pocket comb.   I began to use it out of simple necessity, and neglected to sit in awe of its power and glory. I ask the geeks of Silicon Valley to forgive me.

We have been binary in our office for a long time, but not in our main hospital.  In the office, everything flows by electron, but at the hospital we have been using a kind of EMR-light, call it E-decaf.  Maybe we turn on the machine to check a few labs, order the occasional test, and perhaps send an email.  Thus, even though the docs of our practice spend more than a hundred-fifty hours a week on the wards taking care of 60 patients a day, we were still paper-binder-chart-bound.

But, last week it happened … we crossed the Rubicon … in a blinding flash of bits and bytes, clicks and clacks, copy and paste, we went full-on-no-holds-barred, every-piece-of –data-for-itself electronic and converted to the EMR.  It was glorious!

In the hospital, I had long gotten used to the appalling inefficiencies of the crayon and papyrus world.  First,  find the chart ( good luck… I am sure I have lost a year of my life hunting ). Then, read the prior notes ( which for many doctors, including yours truly, is impossible ).  Find the labs.  Find the X-ray reports.  Check the images.  Call the lab and radiology for the labs for the results that you could not find.  Seek and then check the vital sign clipboard.  Read the I&O record (different clipboard).

Now, there’s time, barely, to see the patient.

Then, painfully, ridiculously, illegibly, write down what you just found, repeating everything you also wrote yesterday (except what you forget or can’t read, which is probably critical) and then put the chart back in the rack (maybe), so that the next doctor can start this whole process over again.

You think I am kidding? Exaggerating? Not the tiniest bit. What I described is what every doctor using chisel-stone-tablet records does every day with every patient and if you have a lot of patients in the hospital it takes a very long wasteful time and is guaranteed to result in error.  Ask any doctor to pull any binder at random from any chart rack anywhere and read it carefully and there is an almost 100% chance you will find a mistake in that record.

Continue reading “Actually, I Love My EMR …”

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As the instigators of the OpenNotes initiative, we are thrilled that OpenNotes is being adopted by the VA. Prompted by Dr. Kernisan’s thoughtful post , the ensuing lively discussion, and our experiment with 100 primary care physicians and 20,000 of their patients ), we thought it useful to offer some observations drawing both on our experiences as clinicians and on ongoing conversations with clinicians and patients.

First and foremost, we don’t have “answers” for Dr. Kernisan. Our hope is to contribute to new approaches to these sticky questions over time. And, remember that patients’ right to review their records is by no means new. Since 1996, virtually all patients have had the right to access their full medical records. What’s new is that OpenNotes takes down barriers such as filling out forms and charging per page, while actively inviting far more patients to exercise this right in an easier and accessible way.

We think of open visit notes as a new medicine, designed like all therapies to help more than it hurts. But every medicine is inevitably accompanied by relative and absolute contraindications, and it’s useful to remember that it’s up to the medical and patient community to learn to take a medicine wisely as it becomes more widely available. A few specific thoughts:

Dementia and diminished physical capacity:

When a clinician notices symptoms or signs of dementia, chances are the patient and/or family has already been worrying about this for some time.  Is it safe for the patient to live alone?  What about driving? How and when could things get worse?  They may actually be relieved when the doctor brings up these topics and articulates the issues in a note. Moreover, their worst fears may prove unfounded, and reading that in a note can be reassuring. But we need to consider the words we write so we don’t rush to label a condition as “Alzheimer’s.”  Being descriptive is often better and more helpful than assigning one word definitions. In itself, OpenNotes reminds the health professional to choose words wisely.  That doesn’t have to mean more work, but we believe it can certainly mean better notes that can be more easily understood by the patient.  We urge colleagues to stay away from “The patient denies…,” or “refuses,” or “is SOB.”

Abuse or diversion of drugs, possible substance abuse, or unhealthy alcohol use:

These subjects are always tough, and what to write down has been an issue for clinicians long before they worried about open records. Over the course of our experiment in primary care, we have heard stories from patients about changing their attitudes and behavior after reading a note and “seeing in black and white” what their doctors were most worried about. Though substance abuse may seem like a particularly sensitive topic, at least one doctor in our study is convinced that some of his patients in trouble with drugs or medications did better as a result of reading his notes. And while some patients may reject our spoken (or unspoken) thoughts that we document in notes, experience to date makes us believe that more patients will be helped than hurt, and that it is worth the tradeoff.

Continue reading “OpenNotes: Drilling Down to Assure a Healthy Evolution”

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