It has been nearly 6 months since I started my new practice, since I took the jump (or, more accurately, was pushed off the ledge) into a brave new world. It seems very distant, like I should get Shirley MacLaine or Gwyneth Paltrow to help me channel my old sad self. It is tempting.
I have a vague recollection, a memory shrouded in mist, where I pondered what seemed like a radical question: What would a health record look like if my only concern was patient care? This was a radical question because in my previous life I was an electronic health record aficionado. I was good at EMR, which meant that I was really good at finding work-arounds:
- How can I work around the requirements for bloated documents and produce records that are actually useful? The goal of records in that previous life was to justify billing, not for patient care.
- How can I work around the financial necessity to keep my schedule unreasonably full and keep my visits unreasonably short and still give good care?
- How can I work around the fact that I am paid better when people are sick and still try to keep them healthy?
- How can I work around the increased amount of my time devoted to qualifying for “meaningful use” and still give care that is meaningful?
Computers were all about automating the drudgery, organizing the chaos, and carving out a sliver of time so I could spend the extra minutes needed to give the care I wanted to give. I was using them to give good care despite the real nature of the medical record: a vehicle for billing.
But that was my past life. Now I no longer have to worry about a Medicare audit (and the looming threat of an accusation of “fraud” for simply not obeying the impossible documentation rules). I no longer have to keep my office full and my patients sick enough to pay the bills. I am actually rewarded for handing problems early, for communicating well, and for keeping patients healthy and happy, as it keeps them paying the monthly subscription fee.
Ironically, in asking the question, what would a health record look like if my only concern was patient care, I was really asking the question: What does “meaningful use” of the record really look like?
Now this question is no longer a hypothetical; it is real.
My rejection of EMR systems that catered to my previous needs and my quest to build one that fits my current needs have given me the chance to work very hard at answering that question. The success of my practice, and the success of other practices like mine, will depend on our ability to answer that question. I am now in a system that actually values communication, prevention, and organization, so I no longer need computers for work-arounds; I need computers to help me reach those goals.
As I’ve spent an enormous amount of time and energy (a.k.a. obsession) on my own system, I have come up with unexpected opportunities:
1. Abandon the artificial centrality of the office visit.
The care I gave in my former life was held hostage to the office visit. This is not only (as I have mentioned before) the unit of commerce, but the unit of documentation. Even in my new practice, where I am no longer loathe to give time and information outside of the office visit, I still am drawn to this unit of documentation. Why? Isn’t in-office care merely one of many communication options? Isn’t it part of a continuum of communication happening over time? Why should I separate the phone call earlier in the day from the visit that phone call prompted? Why should I wait until they are in the office before getting a history?
An example came a few weeks ago when a patient injured her finger. She has close contact with a dentist, who offered to get an x-ray of the hand. I got a secure message with a jpg attachment of that x-ray, revealing a fractured bone at the end of the finger. I messaged her back, telling her what to do about it, including my nurse on the message, asking if we had purchased splints when we started the practice. We hadn’t, and so Jamie ordered them, notifying the patient when they arrived. The patient spent a total of 5 minutes in my office, but the care extended over several days.
This scenario has repeated itself in other forms, including: diaper rashes that don’t heal (more pictures), intermittent abdominal pain, new-onset diabetes treatment, and post-lumbar puncture headaches. Attending to these problems as they happen (instead of requiring office visits) is far better for both patients and me. My availability to help patients in this circumstance lets me handle problems while keeping my office empty, while my empty office enables me to have the time to answer these questions (without the previous angst over lost revenue).
So how do I document this? The records of my former life didn’t consider such questions, but my new freedom brings this issue front and center.
2. Embrace Simplicity and Organization
When dealing with such problems, the focus is not only on communication, but informed communication. Since I am not forced to gather all of the facts at an office visit (a truly impossible task for both doctors and patients), I need to have a better way of keeping track of things. I have to have a record that immediately tells me what I need to know about the person with whom I am interacting. The best decisions are made with the clearest picture of the situation, and I need a record that gives me that picture as efficiently as possible.
This is a far cry from my former life, where I was forced to include massive amounts of E/M vomit in every note to justify billing. The facts were hidden in the medical record, not revealed by it. What was the penalty for not having all the information I needed or for the bad decisions that were the result? Patients stayed sick, came back to the office, and I got paid more.
So, I have been forced to find new ways of organizing information. When I look at a person’s medical condition or a specific symptom, I want to have access to:
- All medications related to it.
- All encounters where it was addressed.
- All associated testing, procedures, surgeries, and hospitalizations.
- The opinions and contributions of other doctors on the issue.
- A clear idea of it’s impact on the patient.
I want this information with as little work as possible so my communication can be as efficient and effective as possible. It’s been a tough task, but I think I’ve found a way to do this without demanding extra work.
3. Give that record to the patient
I am not the only one who needs good information; the patient is an equal participant in these conversations, and the one with the most to gain from good decisions. The only solution I can see is to put this information where it belongs: in the hands of the patient.
If I had embraced this idea fully in my previous life, I would have been faced with a problem: the medical records sucked. The useful information that happened to be present in the record was buried in piles of coding compliance refuse, obscured by reams of superfluous data. Our records were better than most, and yet sharing them would reveal to our patients how little time was spent keeping them organized and accurate. We simply had more important things to do: things that paid the bills.
Creating a truly meaningful and useful record has not simply been something I’ve done for myself; my ultimate goal is to not only give them to the patient, but to invite them to help me in the never-ending task of keeping them organized and updated. My job will be to curate that information, as I better understand which parts of the information should be emphasized, and which should be available when needed.
I’ve got more points to make, but will let that go to another post. The point I want to make clear is this: the radical change in my payment model has forced an equally radical change in the systems that support that model. I can’t put new wine in old wineskins. The medical record of my past life was built to help with the problems inherent in that sad existence, and they served to amplify the sadness of that existence. Now living in a much happier, patient-centered world, I can build something that will increase that goodness and happiness.
Sorry Shirley and Gwyneth. I think I will stay where I am.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.
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I am extremely inspired along with your writing talents as well as with the layout for your weblog. Is that this a paid subject matter or did you modify it your self? Anyway stay up the nice quality writing, it’s uncommon to look a nice weblog like this one these days..
It would look like a 4×6 card with lots of left-over space.
It’s nice to think that the person in charge would think about the patient’s care, but it’s not always true. I would like to think that the person in charge would ask themselves the same question too, “What would a health record look like if my only concern was patient care?”
Fabulous post, Rob! The best description of a patient’s EMR ever.
I read your central theme seems to be that physicians are forced to choose between two belief systems: the institution or the patient. Physicians that are paid through the institution work for the institution using the institution’s EMR. Physicians that are paid by the patient work for the patient and, at least in theory, could be using the patient’s EMR.
Accountable care as the strategy for health reform, (where patients are free to seek care anywhere and doctors like you are willing to provide them advice on when a dentist’s x-ray is good enough) are going to have to deal with this reality.
Institutions like to think of accountable care from the institution perspective (“shared savings” does not mean shared with the patient) but the success of the ACA and meaningful health reform depend on patient-centered outcomes measures where savings go to the patient. The most vivid example of this phenomenon is the dance you hear from delivery networks like Kaiser when their executives are asked why their health insurance costs are not lower than the traditional fee-for-service competitors… I’ll paraphrase their answer as: “it’s complicated”.
I truly hope your post marks the dawn of the patient’s EMR and that you will find and guide a whole army of entrepreneurs who will design software systems that assume the doctor is paid by the patient for advocating for the patient.
Thanks Adrian. It’s way harder than anything I’ve done. Life would have been far simpler if I could have used an already existing system or been satisfied to straddle the two choices. It’s hard to give something that truly centers on the patient, and it is also hard to get them to see the benefit of such a system (as they are so used to episodic “care” that they are saying things like, “when is my physical?” – whatever a “physical” is). About 10 years ago I wrote: People don’t clammer for better care because they don’t realize how bad their care is; and the reason they don’t realize how bad their care is, is because they don’t know how good it could be. My goal is to give people a glimpse of the possibilities. That’s not only a culture change for doctors, it is one for patients as well.
Hello Dr. Lambert:
If you are thinking about putting out a “requirements spec” for review or to interest collaborators, please send this document to me. Thanks in advance.
rogerw at searchrdbms dot com
I have some background and am very interested in the “collaboration aspects” of the ideas you are exploring.
What would a health record look like if my only concern was patient care? What would health CARE look like if our only concern was patient care?
Part of my work is teaching “bedside manner” to medical practitioners. As Dr. Peabody advised in 1926, “The secret of caring for the patient is caring for the patient.” Yet since then so many interlopers forced their way into the examining room that the original occupants can now hardly hear each other.
Restoration of the patient-doctor relationship relies on those two entities finding ways to clear everyone else out. It’s a moral decision, and an economic one too, since one objection from docs is some version of, “I’d lose all those third-party payments! I have kids in college. I can’t do that.”
Yet Rob, bless his heart, is actually doing it and surviving…and, I suspect, doing far better than just surviving. THANKS!!
Jeff Kane MD
Hope you succeed as this is such an important issue and not just in the US. It is about integration i.e. being able to pull information held in other systems (eg lab, radiology, other caregivers), as well as at times push.
Imagine if information on any given patient was only ever collected once! Look forward to your next post
Simplicity and communication. Too bad the Big Iron developers didn’t get that memo.
I’ll say again that I really hope your thinking, on this topic and on healthcare in toto, spreads like a virus. It doesn’t have to be complicated, all it has to do is … work.
I wish a doc with your mindset lived near me.
Dr. Lamberts: Great post with very key and cogent points that foreshadow where we are going or better said where we should be going and what it means.
You use the word communication five times and patient 17 times. These two words come together most importantly when you make point #3 ‘Get That Record to the Patient’. The EMR is what I believe to be a key in creating meaningful patient physician engagement. It is the record that the patient is most interested in learning about and understanding and it is the one tool a HCP can use to bring meaningful communications and learning to the patient. As an advocate of adult learning the EMR is the basis as you identify patient centric world.