There was no mistake, but a bad thing has happened. Despite the best efforts of the doctors, Bob’s wife is very sick. Due to a rare side effect of treatment, her liver is failing. Bob believes this could have been prevented. He is very mad.
“When we go to see the doctor, he stares at the computer,” says Bob. “He does not look at us. Most of the time, the doctor is not even listening to us. He just sits there typing at the keyboard, gaping at the screen. If he had been listening when my wife talked about the pain, then he would have stopped the drug. Then her liver would be fine. She would be OK. All you doctors have become nothing but computers.”
Now here it gets interesting. After I listened carefully to Bob and sat with him at his wife’s bedside, I decided to check “the computer.” There in the doctor’s records I saw a long discussion and analysis of the problem with her liver. Quite opposite of ignoring her, her doctor had listened, had changed therapy and was watching her liver carefully. Sadly, despite the change, her liver had gotten worse. The problem therefore, was not that the doctor was not listening. He definitely was. The problem was that the computer had stopped him from communicating.
It is strange to think that a system of information and data exchange, which allows you to communicate with anyone around the entire world, interferers with connecting to the person right in front of you. We see it constantly as cell phones, Ipads, computers and even that “old” obstructer the television, get between us. At the time we need to communicate most desperately, electronics can block that most human connection of all, the physician – patient relationship.
Let us be clear. Multitasking is a fallacy. We can only do one thing at a time. We cannot drive and text. We cannot talk on a cell phone and listen to our mates. We cannot watch a game on TV and discuss finance with our partners. Most importantly, we cannot focus fully on a patient and a computer at the same time.
Now, I am 100% committed to full computerization of the medical community and exam room. The future of quality, medical safety, and cost containment can only come from full implementation of Electronic Medical Records (EMRs) with system wide analysis and the assistance of artificial intelligence. However, right now is a tough time. We need to figure out the new social mores’ and workflows, which will allow physicians to communicate with patients and with the electronic world.
Therefore, both physicians and patients need to learn new habits and establish slightly different norms for the doctor visit. Patients must understand that for moments the doctor will look at the computer instead of directly at them, and not be offended. Both doctors and patients should turn off their cell phones. Doctors need to take time during each visit to look patients in the eye, instead of ogling the monitor. Exam rooms should be set up to make this easy. It is one thing to type information (smoking history, dates they of medicines, type of surgery…) and another to ask tough personal questions while absorbed in a monitor. Doctors must never teach or give advice while at the keyboard. We must turn, see and touch our patients.
As Bob’s experience shows, even if a physician is doing the correct thing and paying close attention, the patient sees only an uncaring man staring at a screen. The direct contact of the physician – patient experience is still vital. Medicine is about people helping people and the cold interaction of the supermarket checkout line, will not suffice.
James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.
Categories: Uncategorized
I hope your computer is more reliable than mine!
Interesting article and quite the conversation, too.
Oh, Dr. Salwitz, you really are guilible.
Thanks very much.
It seems to spin off naturally from my work.
jcs
“Straw man scenario”…nothing “straw man” about it. It happens all the time. I am trying to deflect nothing. I am trying to kill it dead. I’ll leave the conflating to you.
Of course I have to document. It is the only way to get paid. It is for the benefit of the patient and his care, no and in the future. But it is not done in real time. There are different ways to achieve documentation. Directly interfacing with the computer is the least efficient and least productive. I do not care what you want to put in the computer. I do protest being the secretary. I do protest you forcing me to do data entry. I do protest CPOE.
I am trying to illustrate the relative importance of the computer. It is a filing cabinet.
OK, as I reflect on this proffer…
Are you SERIOUSLY trying to argue to me that your Heroic, Manly, Beneficent ER Derring-do exempts you legally from having to somehow document (even by proxy) your myriad STAT actions and decisions?
If you are in fact who you say you are.
I can pretty quickly find out legally acceptable routine ER procedure. So let’s cut the crap, OK?
“Someone please tell me why you want to force doctors to do clerical computer entry work?”
__
I certainly don’t. You proffer a vivid straw man scenario to conflate the core issue, as a way of trying to deflect it.
Links? (I can’t prove it one way or another; and. “inflicted” is principally just a partisan POV).
How about a stroll down memory lane?
“PROMIS”
http://www.campwoodsw.com/mentorwizard/PROMISHistory.pdf
That’s it? “Right.” Really?
Replacing doctors with computers and algoriths is like replacing German Shepherds and Bloodhouhds with robots and cameras. Neither is a good idea. Neither the skills nor the special senses of either in real time can be replaced by machines. “In real time” is the key denominator.
In an emergency e.g. a bad car wreck, I can collect most relevant information in a moment. Simultaineously I can direct nursing interventions, lab studies,and imaging while intubating and paralyzing the patient (if needed) for airway protection. I can then move on to chest tubes, central lines, controlling bleeding. All the while I can direct the secretary to get me our local trauma center to arrange a helicopter transfer. If too unstable for transfer I can have them call my surgical backup in for emergency evaluation operative interventions.
Someone please tell me why you want to force doctors to do clerical computer entry work?
SOAP notes were adopted, not inflicted.
Thank you for your straightforward reply.
1. I have a twitter account, but I rarely use it. I’m too busy to be constantly interrupted, mostly for trivial stuff. Pear Analytics estimates that twitter traffic is nearly 90% blather.
In general, I find the whole “texting” thing a step backward. SNL even once spoofed it
2. No.
Yeah, it was a weak analogy.
But, we use the internet because the government — DARPA, specifically — created it, via a set of standards. Had that not been the case, we might have a dozen proprietary internets, all silo’ed and expensive (though, some people would like to see that happen).
“allows data to be collected that may be useful in 10-20 years?”
I have to disagree. While the larger benefit — CER — will indeed take years to accrue (and will be fraught with difficulty), the num/denom structured data measures in the MU specs will be useful from the day they are captured. They fact that they pose an onerous workflow “burden” has everything to do with the payment paradigm and nothing to do with the utility of the data.
Just for the record, your position on the value of Twitter, and do you think it has any place in health care?
“forcing IT on health care without understanding consequences.”
Keep digging.
Again, the guy attacks my argument and just validates it by the time he finishes his retort. I believe he is just a front man for forcing IT on health care without understanding consequences.
Hey Mr G, just because I dislike the overall tone of what the Net is doing to human communication does not mean I am a pure Luddite. Besides, if I listen to you, then I would make the mistake of validating your agenda. Getting all dissent to just retire and vanish. Just like politics of usual seems to try these days.
“I see you use the internet.”
And how many of us are using the Internet because the government requires us to do so? How many of us are using the Internet because it’s expensive and slow, but allows data to be collected that may be useful in 10-20 years?
Or are we using the Internet because the technology was allowed to naturally develop to a point where its utility became readily apparent?
DeterminedMD says:
@April 12, 2012 at 7:30 pm
“The world is gray, yet those here who want to keep it black and white only do yourselves disfavor. The physicians who make poor choices are not the majority, and trying to insist we submit to IT fully and completely will not prevail. Putting everyone in an electronic system only creates at least mischief by government, but mostly nefarious endpoints by entrenched leadership. Obama is, in the end, just a power addicted rock star who has no clue to the concepts of humility and honesty. Neither did Bush Jr in office.”
__
Beautiful.
Adjust Reynolds Wrap Haberdashery.
“trying to insist we submit to IT.”
I see you use the internet. Maybe you’d be happier using USPS letters to the editor, handwritten on yellow pads.
“In considering what follows, the reader should understand that front-line physicians are not to blame for the disorder in which they find themselves. On the contrary, physicians are waging a daily struggle to overcome that disorder. But all too often their efforts are unequal to the task, even in cases where favorable outcomes ultimately occur. Some favorable outcomes, as in the case study, are achieved at unacceptable risk, suffering and cost. Some favorable outcomes occur independently of medical intervention or in spite of it, because of the body’s remarkable homeostatic mechanisms for self-repair. Where physician efforts do result in optimal care, those achievements are more personal than systemic. Missing is a system of order and transparency in which to invest remarkable scientific advances and the enormous personal efforts of practitioners. Were those scientific and personal resources invested more effectively, then health care might become as productive as other information-intensive, technologically- advanced endeavors. Were there a system of order and transparency, health care might become an arena of continuous improvement, rather than a quagmire of intractable dilemmas—a source of hope for our economic future, rather than its greatest threat.
A. Implications for reform of medical practice
1. Medicine’s division of intellectual labor
Medical decision making requires sorting through a vast body of available information to identify the limited information actually needed for each patient. That individually-relevant information must be applied reliably and efficiently, without unnecessary trial and error. This requires highly organized analysis. Educated guesswork is not good enough…”
Medicine in Denial, pp 26-27
Y’know, all that “gray area” stuff.
Hmmm… let’s see, who am I to believe? A long nationally-esteemed physician, father of the SOAP note, or some bile-spewing crank hiding behind an unlinked screen name?
I got news for you. Full use of IT in health care is coming. Period.
The world is gray, yet those here who want to keep it black and white only do yourselves disfavor. The physicians who make poor choices are not the majority, and trying to insist we submit to IT fully and completely will not prevail. Putting everyone in an electronic system only creates at least mischief by government, but mostly nefarious endpoints by entrenched leadership. Obama is, in the end, just a power addicted rock star who has no clue to the concepts of humility and honesty. Neither did Bush Jr in office.
MD as HELL says:
April 12, 2012 at 3:54 pm
Bobby,
This is brilliant. This is transformative. Use it. Buy it. Bet your life on it.
What do you need a doctor for?
___
Right.
Bobby,
This is brilliant. This is transformative. Use it. Buy it. Bet your life on it.
What do you need a doctor for?
It all depends on your point of view, does it not? The world lives just fine without being on Facebook, a fact you cannot possibly believe if you are inside Facebook.
For you who have been assimilated it has been transformative, but that is not by definition a “good” thing. It is just “a” thing. For us not assimilated it is a minor amusement and a threat to privacy.
You see it as empowering our profession and globally improving healthcare and cleaning up some mess.
I see it as a technology and a mentality maliciously invading a relationship and a private encounter between two people who wish privacy and anonymity for the content of the encounter, but who have a business relationship where the patient wishes to file a claim for covered services with his/her insurance company.
Why does it have to be a disruptive technology anyway?
That is because it cannot and should not go “fully electronic”. It is about caring for people and being confidential about it. What doctors do does not require a computer in any way, shape, or form, except to get paid and run the office. The patient record is a development FBO everyone else.
Having the patient record online available for the patient in the big wreck and unconscious away from home is nothing more than trying to apply the Happy Meal touch (the same no matter where you are) to healthcare. No one in their right mind would pay out of pocket for the record availability.
There is no”absolute” need for healthcare to be electronic unless you want to run it into the groud and be in power OVER patients and doctors.
Anything substantive to say about the Weeds’ work? In lieu of your indignation with me?
Right.
Thanks for your validating retorts. Why others attempt to dialogue with your insulting comments you try to then rationalize or minimize, that’s their choice.
Here’s an idea, little man, if you do not like what I write, maybe, ignore it?
You write like the class clown sometimes.
Believe me, I try to ignore you as muchas possible. I’d love to hear some of these alleged physician colleagues you claim as peers comment how you conduct yourself in their offices.
Pay attention to the defense mechanisms of those who just automatically dismiss and/or demean non-physician commenters.
Pay attention to the defense mechanisms of those who just automatically dismiss and/or demean physician commenters.
“This meticulous matching process is feasible only with software tools…the tools are trustworthy only when their design and use conform to rigorous standards of care for managing clinical information…Without the necessary standards and tools, the matching process is fatally compromised.”
i.e. not yet ready for prime time.
Where are these software tools?
Have the “rigorous standards” been field tested and proven superior?
Is there a real world example?
What do EHRs, as currently conceived, have to do with any of this?
I say we have a history in this country of adopting promising technology well before its time and clinging to it long after its time and as a result end up spending an inordinate amount of time and money trying to undo the mess and create a new system that uses the more mature technology that actually works. EHRs, as currently conceived, are yet another classic example of this.
“A culture of denial subverts the health care system from its foundation.The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.
Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2½ trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.
This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about.
A simple example will illustrate medicine’s missing foundation. Consider a person with chest pain. Careful review of the literature shows that a practitioner investigating this symptom needs to take into account approximately 100 diagnostic possibilities, involving most medical specialties. Each diagnostic possibility is definable as a combination of simple, inexpensive findings from the history, physical and basic laboratory tests. Checking all of the findings for all of the diagnostic possibilities results in approximately 440 findings on each patient. Each positive finding suggests one or more of the diagnostic possibilities. Each patient’s particular combination of positive findings can be matched against all of the combinations of findings representing the diagnostic possibilities for chest pain. The output of this matching process is an individualized set of diagnostic possibilities, plus the patient’s positive and negative findings for each. These findings constitute initial evidence for and against each possibility. The total set of possibilities (i.e. those for which at least one positive finding is made) represents the diagnoses worth considering for that patient. External tools generate this output by simple matching, without dependence on the fallible minds of costly physicians. The tools distill this output from the accumulated experience of countless patients and practitioners—experience that would be otherwise lost.
This meticulous matching process is feasible only with software tools. The minds of physicians do not have command of all the medical knowledge involved. Nor do physicians have the time to carry out the intricate matching of hundreds of findings on the patient with all the medical knowledge relevant to interpreting those findings. External tools are thus essential. But the tools are trustworthy only when their design and use conform to rigorous standards of care for managing clinical information.
Without the necessary standards and tools, the matching process is fatally compromised. Physicians resort to a shortcut process of highly educated guesswork. They begin with guesses about diagnostic possibilities that might account for the chest pain. Sometimes very sophisticated, these initial guesses lead to further guesswork about what to check during the initial history, physical examination and laboratory tests for investigating whatever diagnostic possibilities come to mind. And then physicians make more guesses about what the data mean, which in turn shapes their judgments about what further data to collect. Varying from one physician to another, these highly educated guesses are not explicit—physicians do not carefully record their thinking or the information they take into account. Inputs to decision making are thus undefined.” [pp 1-3]
__
I really don’t care what you think of me (UntraceableU). Address the substantive issues raise by those with directly experienced, published cred (which you cannot provide).
Suck an egg.
Retire.
Just curious, do plumbers allow the internet to drive their profession?
How about lawyers?
Auto mechanics?
And yet doctors continue to just bend over and take it where the sun don’t shine. Empathy and compassion, enjoy being stabbed over and over with them when used as a weapon against us? It is ok to be harsh and rude and still be a doctor. ‘Cause we have few allies of late, after all, once nurses found out they could be a cheap alternative, everyone has been lining up for our privileges and abilities without the training.
The story of Passover is about Moses leading the Israelis out of bondage into freedom. But, didn’t they turn on him when he made the supreme sacrifice to speak for the Lord, and what was waiting for him coming down Mt Sinai with the 10 Commandments? Revolt, pure and simple.
History repeats itself, we just get more creative in the stupid outcomes. Well, you advocates for making care cheap and universal, careful what you wish for. I’m sure that physician assistant in the ER come 2016 will save your pending burst appendix from peritonitis.
What’s that brown stuff coming at the fan?
Not if we let the advocates of the internet continue to drive the debate. The lose of healthy self this medium has created will terminally alter the physician-patient interaction to a point where doctors will be sued because they foolishly agreed to treat by a screen.
As an addendum, yeah, ok, I KNOW that the billing imperative continues to drive too much of HIT.
“I believe in leaving the diagnosis to the doctors but imrpoving technology to help assist them in doing their jobs.”
__
Yes, and the very point of the Weeds’ book “Medicine in Denial.”
“A culture of denial subverts the health care system from its foundation.The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.
Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2½ trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.
This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about.
A simple example will illustrate medicine’s missing foundation. Consider a person with chest pain. Careful review of the literature shows that a practitioner investigating this symptom needs to take into account approximately 100 diagnostic possibilities, involving most medical specialties. Each diagnostic possibility is definable as a combination of simple, inexpensive findings from the history, physical and basic laboratory tests. Checking all of the findings for all of the diagnostic possibilities results in approximately 440 findings on each patient. Each positive finding suggests one or more of the diagnostic possibilities. Each patient’s particular combination of positive findings can be matched against all of the combinations of findings representing the diagnostic possibilities for chest pain. The output of this matching process is an individualized set of diagnostic possibilities, plus the patient’s positive and negative findings for each. These findings constitute initial evidence for and against each possibility. The total set of possibilities (i.e. those for which at least one positive finding is made) represents the diagnoses worth considering for that patient. External tools generate this output by simple matching, without dependence on the fallible minds of costly physicians. The tools distill this output from the accumulated experience of countless patients and practitioners—experience that would be otherwise lost.
This meticulous matching process is feasible only with software tools. The minds of physicians do not have command of all the medical knowledge involved. Nor do physicians have the time to carry out the intricate matching of hundreds of findings on the patient with all the medical knowledge relevant to interpreting those findings. External tools are thus essential. But the tools are trustworthy only when their design and use conform to rigorous standards of care for managing clinical information.
Without the necessary standards and tools, the matching process is fatally compromised. Physicians resort to a shortcut process of highly educated guesswork. They begin with guesses about diagnostic possibilities that might account for the chest pain. Sometimes very sophisticated, these initial guesses lead to further guesswork about what to check during the initial history, physical examination and laboratory tests for investigating whatever diagnostic possibilities come to mind. And then physicians make more guesses about what the data mean, which in turn shapes their judgments about what further data to collect. Varying from one physician to another, these highly educated guesses are not explicit—physicians do not carefully record their thinking or the information they take into account. Inputs to decision making are thus undefined.” [pp 1-3]
I would agree. The purpose of IT should be to augment the physician. We will always need the human interface to actually “touch” each patient.
jcs
I think you pinpointed something really great in this post. I understand that technologocial advances are a continually changing and greatly impacting devices in our healthcare system, but there still needs to be the physical role of the doctor. I see many websites offering online diagnosis now and I just wonder what direction we will go into next; if we were all doctors it would be a diffferent story; or if the computer was a living being but neither of those things will ever be true. Therefore, I believe in leaving the diagnosis to the doctors but imrpoving technology to help assist them in doing their jobs.
There are several ways by which it will help us gain control. First, by measuring, defining and actualizing quality we will be able to push back against gov’t and insurers and stop playing the stupid, inefficient and frequently wrong pre-cert game. Next, by being able to exactly define our costs at the same time we guarentee quality we will be able to take on risk. Instead of begging for each dollar for each visit we will be able to accept lump sum payment for care (ie take a single payment for a specific pt with a disease or accept risk for a population). This puts the entire decision making structure for care and quality back in our hands. We will be able to eliminate duplicative and unneeded testing (ie the Choosing Wisely project). As it has been said, “if you can’t measure it, you can’t manage it” and our (doctors) failure to manage healthcare has been that we have no real data or knowledge of what we are doing.
jcs
Sorry, I don’t see how EMRs will allow docs to “control the data.” Isn’t the whole point that EMRs will give CMS/insurers immediate access to every dotted i and crossed t in the medical record?
What seems more likely is that we move to having real-time authorization of every single lab test, procedure, office visit, script, with “clinical decision making” guidelines that will take an act of God to override.
Fascinating.
The hope and goal of putting in place a disruptive technology, is that the technology will be transformative . There can be no doubt that IT has already morfed other industries. If the government or other players think that global IT will simply codify the present, they do not understand the power of the technology being released. I.E. Facebook is not simply about college students sharing pictures, but is transforming major parts of business and society. As a physician I see the potential as empowering my profession and thereby globaling improving healthcare (and perhaps cleaning up the mess).
Indeed.
Change.The.Payment.Paradigm.
Some free Lawrence Weed for cheapskates:
__
LJ: Dr Weed, you have had an amazing career implementing a needed change in how patient data is handled through the POMR. Today, you outlined another major change that needs to be incorporated if the practice of medicine is to be improved. On the basis of your experience as an innovator, and knowing what you know today about medical education and the practice of medicine, are you optimistic such changes will be forthcoming?
LW: Based on what I know about all the vested interests in the present medical education system and in the present practice of medicine, I am not optimistic such changes will be forthcoming. For change to occur, it will take extraordinary leadership with the power to switch all the capital and resources now going into a misguided form of medical education to a National Library of Couplers and a whole new paradigm for medical education and practice as described in Section VIII of the Medicine in Denial paper. A paradigm in which knowledge is in tools instead of heads, in which patients from childhood on are involved in the use of those tools in their own care, and in which there is a new division of labor among clinicians. If change is to come, it will take courageous leadership from present day Ingelfingers and Hursts. If the medical establishment and the government fail to lead the change, then patients will demand such a change once they understand the deep faults in the present system.
LJ: Do you believe people will heed your warning?
LW: There were many warnings of the disaster coming in the financial system and all were ignored. The present health care system is a medical and financial disaster, and perhaps only the disaster itself will get bad enough to change the status quo. My fear is that the government will spend billions computerizing the present chaos and will remain unaware of the fundamental changes that are so badly needed.
http://xnet.kp.org/permanentejournal/sum09/Lawrence_Weed.pdf
I may have drank the Koolaid, but I think that controling the data will give physicians the power to control healthcare. I think that EMRs, etc are about rebuilding the system, but perhaps with doctors calling the shots. You are no doubt correct that the entrenched powers (insurance, govt, pharma…) will try to use IT against us (as they have successfully for 20 years), but this gives an opportunity for the ones who best understand medicine, doctors, to take dictate the future.
My concern is that we will be unable to reap any of the predicted benefits of EMRs (as other countries have) as long as they’re designed to be used in our non-functional ICD/CPT/pre-auth/med mal/coding for dollars system. They may even be used to perpetuate those problems. Rather than obsessing about putting icing on a rotten cake, wouldn’t we be better off by first baking a better cake?
Well said.
The future is a painful not far away.
jcs
“Physicians tend to question whether detailed data collection is truly productive at the outset of care. The only advantage of detailed initial data, it seems, is identifying as many diagnostic or therapeutic options as possible. Most of those possibilities will turn out to be inapplicable to any individual patient (i.e. located in the outer circle of information, as described in part IV.F). Physicians believe that their expertise enables them to leapfrog over the outer circle. They can rapidly identify the options of probable relevance to the indivi- dual patient. Those are the options worth investigating (the middle circle), and only limited data are needed to identify them, physicians believe. The impor- tant question, on this view, is whether objective evidence of probability, rather than subjective, variable physician judgments, should be the basis for identifying the options worth investigating. Whatever the answer to that question may be, expert physicians collect initial data selectively rather than exhaustively. If and when it becomes necessary to investigate improbable options (rare diagnoses, non-standard treatments), then more detailed data collection may be needed and specialists may be consulted. An iterative process of successive elimination thus occurs. On this view, collecting detailed initial data at the outset of care defeats a primary purpose of expert functioning in the initial workup—to avoid unnecessary data collection.
This entire point of view rests on a mistaken premise—that detailed initial data collection is not needed to identify the options worth investigating. The reality, however, is the opposite. The only reliable way to determine the options worth investigating for an individual patient is first to collect patient-specific data in great detail.
Much of the detailed initial data will indeed turn out to be irrelevant. But the relevant and irrelevant data cannot be distinguished in advance. They vary for each patient with the same presenting problem. Detailed data must therefore be gathered at the outset. In no other way is it possible to identify all options of potential relevance, and narrow them down to options of actual relevance, for an individual patient. These threshold inquiries are compromised when detailed data collection and analysis are deferred.”
– The Weeds, Medicine in Denial”, page 85
No major industry exists, except medicine, which has not gone fully electronic. It will not be possible to save the massive dollars needed or truely produce dependable high quality healthcare without unified medical records and the application of informational data bases & standards (i.e.UptoDate, WebMD…) if we are not electronic. The data entry issue is a royal pain and hinderance but does not compromise the real and potential benefit. That research is mixed regarding quality, efficiency and cost is a statement of the infantile stage in development of EMR/data/analysis integration. By doctors pushing thru EMR and screaming about it’s short comings, this can be solved. We are being disrupted by a positive disruptive technology and we have to disrupt back. In the long run I see full implementation as an opportunity for doctors to take back control of medicine.
With all due respect to your insightful article, your last comment needs some clarification. Why is there an “absolute need” to go fully electronic when it is admittedly “clunky” and not ready for prime time, producing complaints from the same media sources and patient groups that once demanded its implementation and there is a lack of well constructed(and not merely observational) literature supporting any meaningful improvement in quality outcomes associated with its use?
No, as usual, you would both be wrong. But, thanks for the chuckles.
I get it perfectly well. I work with doctors and clinics every day as part of my REC job. And, no one can accuse of being an unreflective HIT cheerleader.
e.g., see my MU Cert spoof at
http://ClinicMonkey.blogspot.com
No, I would hypothesize that Mr G is equally busy holding his electronic devices in the office and wouldn’t be surprised he and the MD text each other in the visit. Hey, Mr G, do you turn off your cell phone in the doctor’s office? Gotta love those patients who take calls while they are allegedly discussing health concerns!
We are in a transition period. Clunky EMRs which make it a challange to enter data but with an absolute need to go fully electronic. It will be some time before we figure out new practical but humanistic work flows and for the EMR industry to fix the present software which demands painful human work-arounds.
jcs
The problem here is not EMRs per se. Due to a combination of: 1. clunky EMRs and the need to maintain productivity, and 2. requirements of meaningful use, PCMH, etc., it is now considered almost mandatory to complete the note before the patient leaves the office. Previously, this work was done in-between patients, at lunch, at the end of the day, on the doc’s time. Now, 5-10 minutes of the 15 minute visit is used for secretarial work, resulting in rushed, sloppy documentation, and less time for pnysician-patient interaction.
I guess you don’t really get it. Electronic medical records are far from perfect(as a matter of fact “perfect” and EMR should not even be in the same sentence together) but the public and the media screamed for its implementation prematurely, without considering any of the the negative consequences. Now they are getting exactly what they asked for, that’s the point.
Sounds like you are easy to please. Or maybe your doctor gives you only the care you let him provide instead of the care you really need.
Yeah
Perfectionism wishful thinking sux.
If this wasn’t so comical, I would cry. For years newspapers and periodicals like the NYT and Time Magazine denounced physicians as a bunch of Luddites for dragging their collective feet at not adopting EMR. They were convinced that computers would enhance every aspect of medical care and we were standing in the way of progress. Now that EMR is a reality in most physicians offices the SAME media sources are denouncing physicians and the depersonalization that accompanies our new role as data entry clerks and the lack of eye contact and attention associated with it . Prior to EMR, I observed a patient while I took their history, looking for subtle physical clues that might help with diagnosis. Now I am reduced to having a conversation with an LCD screen. Be careful what you wish for, you might just get it.
Praxis claims to have covered the visit impressionistic charting nuances. The “non-template EMR.”
I’m not sure. I only have one REC client on Praxis. I asked him how he liked it.
“Fine, I guess. What are my choices?”
My Primary engages me quite effectively, while iteratively looking up and down from his EMR notebook during our SOAP part of the visit. His looking up and down is NO DIFFERENT from his would-be-otherwise scribbling in a paper chart.
No different.
Other than the fact that the data will be there for easier recall and evaluation (along with my prior visits’ data.
I have one word for people like you: Retire.
Or, go cash-only concierge.
Just like an old fashioned written or dictated note, I find in an EMR there are somethings that are easily templated (meds, VS, basic PMH, SH, FH) and some that require depth and color (impression, complex plan, perhaps the HPI). Sometimes the full depth of a pt is just in an added comment (i.e. frightened young mom who recently watch a friend die to the same disease).
It is an art I have not yet mastered.
jcs
If you are not looking at the patient, you are not doing your job. You are not seeing the fear or the evasion or the inquiring looks, the nonverbal communications that are part of every encounter. The rest of the story will be missed.
If all the BS is so damn important, then jsut video everything and let the gov’t or insurance company pull it out.
I recently started a third job in a different ER. The docs record on manual T system templates. Some of the docs take them in the room, as the system suggests, and complete them at the bedside. I complete them outside the room. They take forever. There is no flavor of the visit contained in the product. Fortunately I am paid by the hour and not on productivity. My own company is being forced into templates at my main hospital. The productivity will definitely suffer and the hospital will definitely be making up the difference. It is not better. It is stupid.
I suspect you are correct…there will be a slightly different solutions for each of us. Some, like a doc I met the other day at an IT conference, will take brief written notes and convert to EMR at their desks, others will go back and forth while they are talk to the patient, some will dictate with voice recognition with the patient present (good for derm, bad for onc) others (i.e. me) who can touch type while maintaining eye contact with the patient, may be able to get much of the note done in real time. However, for now, until we really solve the data entry problem, the key is not to let the machine get in the way.
jcs
Actually, the solution is to not do things differently than we were trained.
Docs need to realize that documentation chores and other secretarial tasks (pre-auths and such) are to be completed AFTER the visit is over.
If the patient sees the doc using time they are paying for to act as a data entry clerk, they should demand that it stop.
Waiting to hear from the two other MDs . . .
I think this post suggests a good compromise: Doctors, acknowledge the EHR at the beginning of an appointment, saying something like, “I might not be look at you, but that doesn’t mean I’m not paying attention.” With that said, patients, keep talking, and don’t expect that normal conversation etiquette has to apply to the entire meeting.
“Therefore, both physicians and patients need to learn new habits….”
The author identifies a problem, but then this is the solution? “just do it different.” OK, I will. Me and the three other MDs who read this blog. But what about the other 799,996 practicing docs? Sorry, but “just do it different” isn’t an answer. I know, when one of the all wise educated elite makes a pronouncement, the rest of us should fall in lock step behind, but the real world doesn’t work that way. People do what people do. It’s like that big beautiful lawn on my college campus – beautiful except for the worn dirt path diagonally through the middle. There were nice side walks all the way around, but still people walked on the lawn. Adding barriers and bushes didn’t help – people just walked around them. Finally they poured a cement path over the worn dirt path and bingo, beautiful lawn once again with happy college students taking the shortest path without getting their shoes muddy.