Physicians

The Doctor Is In and Logged On.

ParikhWow. I’ve just taken care of three patients in 12 minutes, and I didn’t do it by “churning” them through my office as if it’s some sort of factory assembly line. Rather, those patients (their parents, more specifically — I’m a pediatrician), e-mailed me over a secure network with questions and descriptions of signs and symptoms.

One mother attached a digital photo of a rash on her 3-month-old daughter’s face; it turned out be nothing more serious than baby acne (it’ll go away in a month or so). Another mom had noticed that her son was missing one of his pre-kindergarten immunizations (she had pulled up his shot records online) and requested that I order it. And the father of a 5-month-old boy told me that his son has been constipated off and on for the last month. I e-mailed him a questionnaire so I could determine whether the family should try something at home or bring the child to the office.

In the past, these parents would have left a phone message and we probably would have spent the better part of a day or two playing phone tag. Or they would have had to make an appointment, strap their children into car seats, pack diaper bags and snacks and sit in a waiting room full of sick children — only to spend 5 to 10 minutes with me while I told them everything was fine. Instead, we fixed the issues by e-mail, allowing parents to stay in their lives at home and at work.

Such interactions are no longer a pipe dream for the future of medicine. This is how I (and several thousand of my colleagues at Kaiser Permanente in Northern California) practice medicine every day. In 2006, we implemented an electronic medical record system and haven’t looked back.

The advantages

Medicine is a multi-trillion-dollar-a-year business, yet most doctors still run it like middle-school students passing notes in a classroom: A doctor scribbles something on paper and passes it to a nurse or another doctor, who then scribbles something back. Later, somewhere on those same sheets of paper, another doctor will write something else that’s barely legible. It’s a primitive, fragmented and unreliable way to do business.

In my pre-electronic days, it wasn’t unusual to get an incomplete medical record because various parts were stuck in storage or older pages had simply fallen out.

Electronic medical records eliminate many of those fundamental problems — notes, orders and prescriptions are clear and contiguous. There’s no waiting for paperwork. And if a patient of mine shows up in another office across town (remember, Kaiser is an integrated system — we all share the same computer network), a doctor whom I have never met can see what I’ve written, my patient’s list of problems and what I’ve done for the patient in the past before he or she even sets foot in the room to talk to the patient.

Such record systems can alert us to possible medication errors or dangerous drug interactions. They can continuously be updated to identify best practices. And they talk to patients as well, allowing them to access past-visit information and immunization records and to make appointments and send e-mails to their doctor.

Finally, they help better integrate care. When a woman came to a routine eye appointment in our medical group, the nurse noticed a “preventive health prompt” in the patient’s medical record saying that she was overdue for a mammogram. The nurse booked her for a mammogram and, when the woman had it done a short time later, her doctors discovered early breast cancer. She was treated and remains well today.

Valid criticisms

All of this being said, electronic medical records have their critics.

In March, as President Obama was announcing his plans for healthcare reform, Harvard doctors Jerome Groopman and Pamela Hartzband wrote an op-ed in the Wall Street Journal questioning some of the records’ purported benefits. They wrote: “A study of orthopedic surgeons, comparing hand-held PDA electronic records to paper records, showed an increase in wrong and redundant diagnoses using the computer — 48 compared to seven in the paper-based cohort. But the propagation of mistakes is not restricted to misdiagnoses. Once data are keyed in, they are rarely rechecked with respect to accuracy. For example, entering a patient’s weight incorrectly will result in a drug dose that is too low or too high, and the computer has no way to respond to such human error.”

That’s a valid criticism, but these are data entry and vigilance errors by health professionals taking care of patients, the kind that can be remedied by holding doctors and others accountable for the accuracy of their documentation.

Other critics of electronic medical records have expressed concern about the security of computerized health information, and what happens to healthcare should a system crash. These too are legitimate concerns, but they’re no different than the ones in other industries in which data stability is critical, such as finance. We can’t imagine a world in which we couldn’t bank online, over our mobile phones or by using an ATM. Why should medicine be any different?

Electronic is better

Like most doctors, I’d like more time in my day to finish my notes or return the e-mails I receive each day. Electronic records don’t save me or my staff any time — medical assistants and others have to type in weights, measures and other data. Typing is nowhere near as fast as jotting chicken scratch.

On the other hand, I can time shift — if I want to be home by 5:15 p.m. to play with my daughter before she goes to bed, I can log in remotely and finish my work later.

Ultimately, getting away from a pen and paper is better for my patients. So though electronic medical records are far from perfect, you’d have to tear my cold, dead hand from the mouse to make me go back to relying solely on pen and paper.

Parikh, a Walnut Creek, Calif., physician, writes the Vital Signs medical column for Salon.com . This piece first appeared in the LA Times.

Livongo’s Post Ad Banner 728*90
Spread the love

15 replies »

  1. Additionally some of the nicer pools which offer private
    cabanas have excellent outdoor entertainment and dining
    options making the experience particularly enjoyable.

    Instead you have to suggest that there is more to you than meets the
    eye and that he was not aware of this new interesting aspect of your
    character. Using a facial mask on a weekly basis will
    also add to the re-hydration process.

  2. AND AGAIN SOMEONE IS BRAGGIN ON KAISER IT IS NTO A GOOD HEALTH PLAN IT IS PREVENATIVE NOT WANTING TO TAKE CARE OF OLD PEOPLE THEY DO NOT TREAT EVERY ONE LIKE THEY WANT THEM TO LIVE MY FRIEND GOES THEIR MADE THE REMARK NOW THAT SHE IS 78 THAT SHE HAS COME TO REALIZE THAT THEY DONT’ CARE AFTER 65

  3. AND I AM NOT BEING MEAN, YEARS AGO MY FRIEND OF MANY YEARS MARRIED A WOMAN YES A MUSLIM AND HE CAUGHT HER IN BED WITH A MAN HE FILED FOR DIVORCE AND )YOUR RULES WERE FATHER OR BROTHER HAD TO KILL HER IF SHE GOT DIVORCE) SO THEY KILLED HIM WOW WHAT A WAY TO BELIEVE IN GOOD OLD RULES FROM COUNTRIES THAT ARE IN THE BIGGEST MESS IN THE WORLD AND THEY WANT TO MAKE OUR LIKE THEIRS

  4. I would say your a Muslim like he is ? If I am right you would follow what he says> His Health care would never qualif for a GOOD Dr to pass
    Old People would have totell him as in HIM that we have to die page 425 so why in the world would a good American Dr. ever do any thing against the welfare of taking care of any one who is Ill.
    AND HE WON’T TAKE HIS OWN HEALTH CARE BILL AS HIS SO THAT IS ALSO A REALLY MAJOR THING THAT SAYS HE IS EVIL AS EVIL IS.
    HE DOESN’T CARE ABOUT ANY OF US AND HEALTH HE ONLY IS CONCERN ABOUT RUNNING AMERICA AND PEOPLE LIKE YHOU ARE THERE TO KISS WHEN HE BENDS OVER SORRY BUT THAT IS HOW I SEE YOU AND THE OTHERS WHO ARE LIKE LITTLE PUPPPETS WHO FOLLOW A EVIL PERSON TO HELL

  5. > I wish that what is said to me as a patient were even
    > parallel to what is said to the physician receiving
    > the EHR.
    > They use an EHR system that I found useful
    > but, I’ve already found errors in the record
    OK but don’t think these problems are absent (or even mitigated) in handwritten records…
    t

  6. I so agree with Pam Drew. I’ve been a health care consumer for almost 40 years due to IBD and other issues. I cannot even remember all the docs I’ve seen and finding old medical records would be an insurmountable task should they be needed. I’ve recently changed my primary care physician, so my primary and gastroenterologist are now in the same system. They use an EHR system that I found useful but, I’ve already found errors in the record after just a few months and entries that give rise to lots of questions. And things that made me go “What?” So I have the task of trying to get things corrected. I really do wish I could email my docs because after 40 years, I’m a pretty savvy patient but, I can see how that would not be helpful to some patients. I am happy and applaud the new major interest in electronic medical records but, I shudder to think how mistakes in records might really make a difference to someone when they’re ill. I pray I’m never in a coma or something and cannot speak for myself. Fact is, even my family is not up on all of my medical history, I mean the little things that really may mean a lot but, I’m the only one that knows them. I hope I’m not just being a little paranoid.

  7. Comment on The Doctor Is In and Logged On July 20, 2009 THCB
    Dear Dr. Parikh,
    I certainly agree with much of what you said. However, you appear to be unaware of several aspects of the Kaiser Electronic Medical Records system.
    You say “Wow. I’ve just taken care of three patients in 12 minutes, and I didn’t do it by “churning” them through my office as if it’s some sort of factory assembly line. Rather, those patients (their parents, more specifically — I’m a pediatrician), e-mailed me over a secure network with questions and descriptions of signs and symptoms……In the past, these parents would have left a phone message and we probably would have spent the better part of a day or two playing phone tag. Or they would have had to make an appointment, strap their children into car seats, pack diaper bags and snacks and sit in a waiting room full of sick children — only to spend 5 to 10 minutes with me while I told them everything was fine. Instead, we fixed the issues by e-mail, allowing parents to stay in their lives at home and at work.
    I reply
    ***Certainly healthy, cuddly babies born in the Kaiser system and whose parents are electronically savvy, are treated cheaply and conveniently by pediatricians using the email system and referencing their EHRs. E-mail certainly has an advantage or two over the previous system of calling a receptionist in your own doctor’s office and speaking to an advice nurse there in the same place usually within fifteen minutes to half an hour. It certainly has even more advantages over calling a Kaiser central call center, identifying yourself by number to a gatekeeper whom you don’t know and never will know, and possibly speaking to an advice nurse of the same sort. E-mail leaves an electronic thread which can be easily reviewed. If the parent has a great deal of medical knowledge and can explain the symptoms clearly and concisely, the child benefits. If the parent doesn’t, possibly a few useless clues are missed. If all can be done in one transaction, wonderful, but if there are layers and questions need to be asked ***
    and answered, a phone call becomes necessary. You get to hear the parent’s voice. You may be able to hear the baby crying. You can subtly assess the amount of health knowledge and experience the parent has. You have a multisensory real time interactive experience so to speak.
    The previous paragraph between the asterisks is over 1000 characters (1239 to be exact). One thousand characters is what each Kaiser patient is allowed per e-mail. Multiple emails are not permitted to the same doctor, at least successively, to get around the 1000 character limit. My communication would have ended at the second set of *** The limit comes on only when you have reached and usually exceeded it. It takes a few of us some time to figure out why we can’t send our email. If we don’t figure it out fast enough we are timed out AND we lose our composition. A word to the wise, compose offline using Word (multiply word count by 5 to get a character count) or Text Edit Plus which has a character count. If you are the person who is sick or if you are old or if you can’t type for some reason, it is wise to have a tech savvy friend. Thank goodness the previous years having multiple days when Kaiser EHR and email were down are over now!
    You say “In my pre-electronic days, it wasn’t unusual to get an incomplete medical record because various parts were stuck in storage or older pages had simply fallen out.
    Electronic medical records eliminate many of those fundamental problems — notes, orders and prescriptions are clear and contiguous. There’s no waiting for paperwork. And if a patient of mine shows up in another office across town (remember, Kaiser is an integrated system — we all share the same computer network), a doctor whom I have never met can see what I’ve written, my patient’s list of problems and what I’ve done for the patient in the past before he or she even sets foot in the room to talk to the patient.”
    If you are speaking of the system in place in the Bay Area, note that there are actually three different jurisdictions for Kaiser EHR (Health Connect, proprietary software from Epic, using Citrix servers, certainly imminently scalable now). The computers do not talk to one another. As it was explained to me, this creates a firewall which guards the privacy of patients. As it has worked for me, Kaiser doctors in Marin cannot see more than a skeleton listing of office visits, limited to generally one word descriptors and including blood pressure and body mass index ranges, made to the Oakland Kaiser facility. Oakland’s electronic records started about four years ago. Prior records, paper ones, are stored offsite. Paper files can be requested by Marin Kaiser doctors much like a University of California Berkeley student might borrow a book from from Stanford. The doctor who requested the file must read through it and scan what he wants for his file on his patient and he must return the file. Whatever he judges worthy is included. Whatever he judges dross is left out. Otherwise no information is passed from one jurisdiction to another. Some doctors take the time to peruse and summarize a transfer’s file. Others don’t.
    If a patient has used the facility in San Rafael part of the time and the facility in Oakland part of the time Kaiser Marin doctors see only the San Rafael info and have no inkling that there is more info in Oakland and vice versa. There is so much faith in computers as a godsend that considerations of completeness, accuracy, and above all, periodic intelligent updating so that pertinent info is moved forward to a prominent place, are scarcely raised. I doubt that doctors are compensated for perusing the computer file, let alone for requesting the paper file.
    Updating by relevance rather than recency is certainly not being done. As your quote illustrates, doctors believe that they are seeing the whole picture or enough of it so that they can make good decisions. It pays to be a healthy baby born at Kaiser whose middle class, tech savvy parents stay in the same place year after year. If you are older than four you have essentially lost your past unless you are more successful than I. Scanning all of the previous medical history (paper) for patients is immensely expensive. Even creating a summary of that history would cost Kaiser millions. You can get your last year of records put on a flashdrive for $5.00 or you can have your paper records copied (charged by the page) and carry them around with you.
    As one young Kaiser employee said to me “Who needs more than four years of records anyway?”
    Zeroing in on your statement “There’s no waiting for paperwork.”
    I reply that I moved to Marin from the East Bay July 1, 2008. I picked a Marin physician and requested that my file be sent to Marin to my new physician shortly after July 1. The computer said the file was sent but the Marin medical secretary said it had never been sent. I delayed meeting my new doctor thinking the file would turn up. I met him the first time July 21 by necessity as a follow up to an emergency room visit for asthma. He did not have my file nor was he troubled by this. I met him again on February 27, 2009, having waited 3 months for the file to be found. He still did not have my file. After I appeared in person in Oakland to request that my file be copied for myself on 12/12/08, I finally received it March 19, 2009. Now I realize that my actual medical file was/is of no consequence and that the skeleton outline and the single word all caps ailment descriptors which greet the physician who types in my number at Kaiser is all that matters unless I myself somehow make a difference, highly unlikely. You are completely correct: there’s no waiting for paperwork. Paperwork is irrelevant. Complicated, chronic, rare forms of diseases are contraindicated under the circumstances.
    You say “Electronic medical records eliminate many of those fundamental problems — notes, orders and prescriptions are clear and contiguous. There’s no waiting for paperwork. And if a patient of mine shows up in another office across town (remember, Kaiser is an integrated system — we all share the same computer network), a doctor whom I have never met can see what I’ve written, my patient’s list of problems and what I’ve done for the patient in the past before he or she even sets foot in the room to talk to the patient.
    Such record systems can alert us to possible medication errors or dangerous drug interactions. They can continuously be updated to identify best practices. And they talk to patients as well, allowing them to access past-visit information and immunization records and to make appointments and send e-mails to their doctor.
    Finally, they help better integrate care.”
    I reply that I wish it were all true. EHRs are much better than nothing and readable notes beat illegible ones hands down. Computers sort fields (drug interactions, for instance) incredibly quickly. I also wish there was some vestige of equality in the doctor patient relationship. I wish that what is said to me as a patient were even parallel to what is said to the physician receiving the EHR. I also wish that I could have access to physician to physician notes re my ailments without having to subpoena them. Such notes are physicians’ property, not mine, even though they affect me greatly.
    I’m sure that you are a good physician. I’m sure that you are brilliant and computer savvy and young, that you will help more people than you hurt. I’m sure you work very hard and that you get rave reviews on the Kaiser opinion surveys.
    I am just as sure that keeping your average patient contact down to 15 minutes or less, aided by all sorts of technology doesn’t give you a snowball’s chance to diagnose complicated problems. You cannot know your patients. Their charts are not substitutes for them. You have been taught about your superhuman abilities and your infallibility and you must believe… because you have no other choice in order to keep working. I am also sure that a corporation whether for profit or ‘nonprofit’ is the best form possible to deliver health care to 7-digit numbers standing for people with histories drawn from thirty or more common medical disease descriptors and that I would rather die at home than in the hospital. It doesn’t take 1000 characters to say thank you for caring, but it is best said in person.
    By the way, I received no compensation of any kind for this commentary.
    Pam Drew

  8. I’m all for new methods of health care. I’m very close to not caring how much a doctor would charge. My problem is FINDING A DOCTOR to help take care of my grandchild who has a mental illness. Have any of you bloggers ever spent hours or days in an emergency room, only to be told there are no beds for your child. It would be better if the child had a medical problem; then the doctors would crowd around the bed trying to help. If anyone has any answers for me, please — I’m open to suggestions. signed, desperate grandmother

  9. Looks lie doctors are beginning to get out of the pre-information age era. They still have a long way before they arrive. This will be a major part of health care reform. The future is starting to take hold.

  10. Rahul, Thank you for writing this post. I am excited to hear that care for your patients has improved with the use of electronic records.
    So many have voiced concerns that implementation of EHRs will require additional time by providers for delivery of care, or that the costs for implementation of EHRs outweigh the benefits, or even provider’s apprehension about interaction with their patients digitally.
    Although HIPAA Privacy and Security Rules for EHRs (as part of the HITECH Act) have been “greatly enhanced” with the potential for increased enforcement, I believe that in the long term (as we become more informed), the benefits of EHRs will indeed be of value to patients, providers and the industry in general. That said, if you are interested, you can access a FREE online addition of “The HIPAA Survival Guide” that I co-authored with a Privacy Lawyer at http://www.hipaasurvivalguide.com.
    Best regards,
    Deborah

  11. Rahul and Doug what are the legal requirements of providing medical care via email? I have been trying to install telavisits into limited plans for lower paid employees and would think email would be a step up from that, webcam and sending pics would have to help.
    What would you bill these out as $ wise? Tela we can get for $35 which is a great deal, specially for single parents with lots of kids who don’t have the time, or even the transportation to get to the Dr.
    Plan I am working on now we pay the full cost for 6 visits a year.
    What would be nice to find is more robust language offerings. If I could get spanish speaking doctors or other even less common languages to treat patients in these rural communities.

  12. Diagnosing and treating by telephone has always been considered bad medical practice. But now, if we do it via e-mail, it’s considered good?
    Are quick, convenient, and cheap to be the ultimate standards by which we judge the quality of medical care?

  13. I strongly favor e-health records. But I have grave concerns about tele-medicine (with some notable exceptions like military or other geographically distant patients)
    The tele-medicine advocates need to carefully study the the literature on the merits of face to face(flesh time)interaction. Much transpires(measurable)which cannot be duplicated electronically.
    The excesses of tele-medicine could spell the end of the doctor-patient relationship and medicine at its very best.
    Dr. Rick Lippin
    Southampton,Pa
    http://medicalcrises.blogspot.com

  14. Dr. Parikh,
    Enjoyed your post. I am the CEO of a large physician network in CT.
    There were four new CPT codes for 2008:
    99441 PHONE E/M BY PHYS 5-10 MIN
    99442 PHONE E/M BY PHYS 11-20 MIN
    99443 PHONE E/M BY PHYS 21-30 MIN
    99444 ONLINE E/M BY PHYS
    Unfortunately, in my state (CT) hardly any of the large healthplans will pay for these codes, even though Medicare pays for 99441-444 in 2009 ($15-$41). It is hard to get physicians to adopt new modes of patient care if they are forced to make large investments in technology with scant prospects for reimbursement for services utilizing this new technology. I guess we all must hope that the big EHR vendors will all provide free upgrades (dream on) to make sure their products can guarantee ‘meaningful use” in 2011 so docs can receive some of their investment returned. I’m not holding my breath.

Leave a Reply

Your email address will not be published. Required fields are marked *