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Monday Oct 10, 2016

Despite Flaws, Potential Vast for Health IT

I recently finished a long weekend of call for my group practice. I managed pages from our answering service and phone calls from nursing homes, and followed up on laboratory and imaging studies, emergency room visits, and hospitalized patients. All the details that go into covering for six other physicians and two physician assistants can be complex and time-consuming.

Of course, it could be a lot more difficult. When I started practice 32 years ago, if you wanted to look at an X-ray, compare labs from a prior visit, look at chart notes, review an emergency room visit or find any other information about a patient, you had to physically go to your office or hospital, find the paper record, pull the X-ray films and try to track down the information.

Fast forward three decades, and all the pertinent patient information is digital. All of it is accessible remotely, through web-based applications (even on my cell phone if I am away from a computer).

A mother who wanted to know if her 15-year-old daughter had a fractured finger had a video call with me while I looked at X-ray images on my computer.

An emergency department physician 150 miles away in Seattle called me about one of my partner's patients, who was there with chest pain. I was able to direct print an EKG from two days earlier to a web-based printer in that Seattle ED, along with a medication list and medical record summary. (Someday I will be able to push a continuity of care document but not yet!)

When I discharged a pneumonia patient from the hospital, I brought up his chest X-ray on my tablet to show his family, placed his discharge orders, sent his discharge medications and completed my discharge summary all while I was at his bedside. His kids and grandkids had a good laugh about my poor typing skills, but I got the job done pretty efficiently.

Despite my lack of typing skills, I serve as the chief medical information officer for our community hospital and a growing integrated health system. As we move our medical community forward, expanding our electronic health platforms and working to become more tightly connected with a shared electronic health record (EHR) system, I thought about the challenges all of us are facing with the looming implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), physician resiliency and other concerns. I wanted to share these bright spots in what, for many, has been a fairly bleak landscape.

Family physicians account for one of every five outpatient visits in the United States. And although many of us were early adopters of EHRs and continue to see the promise that integrated systems can bring to the quality, safety and efficiency of our patient care, nearly half of U.S. physicians say they are suffering from symptoms of burnout and place much of the blame on EHRs and the associated "WAC" -- work after clinic.

Recent surveys suggest that physicians put in almost twice as much time working with EHRs than they do in face-to-face contact with their patients, including at least one or two hours of additional work after getting home at night.

Early surveys and studies suggested that a majority of physicians experienced reduced productivity with the added work load that comes with the initial adoption of EHRs while others have seen practice efficiencies and patient volumes increase above pre-implementation levels.

Our EHRs improve our ability to capture analytic data about our practices, collect information about population health and share information with other physicians and health care institutions, although they are not perfect by any means. Improved legibility, improved access to information and decision support tools are all important benefits of EHRs.

So how do we reduce the data entry burden on physicians and still have a comprehensive medical record that accurately reflects a patient's medical history and important aspects of ongoing medical care? The answer lies partly in expanding the role of all other members of our care team in contributing to documentation in the medical record, and partly in transforming payment for medical care to get us away from the documentation requirements mandated by evaluation and management (E/M) coding.

The AAFP is working on all fronts to push for comprehensive payment reform that will get us off the E/M treadmill. At the same time, we are helping to educate our members about tools and techniques that will help drive the most benefit from EHRs for our patients and practices.

Innovative practices in family physician-led, team-based care were an important highlight of the recent Family Medicine Experience (FMX). The Connecticut Institute for Primary Care Innovation brought us the Office of the Future, a hands-on demonstration of new practice designs and technology for primary care transformation. Those were not able to visit FMX this year can see the innovative ideas online.

The Office of the National Coordinator for Health Information Technology recently launched a new website, the Health IT Playbook, which offers health care providers guidance on how to implement and use health IT to advance care information and delivery.

Among the important questions that the playbook helps to address, I think these three get at the heart of the true value of EHRs in the MACRA system:

  • How do I redesign workflows to improve and optimize practice efficiency and effectiveness?
  • How can I activate and engage patients and their families?
  • How do I learn more about improving patient outcomes and prepare for new quality payment programs?

I encourage you to read the Health IT playbook, including stories about innovative family physicians like Jennifer Brull, M.D., who improved cancer screening in her practice using her EHR's tools. She is making a direct and important impact on the lives of her patients. Her incredible and infectious smile says it all: Here is a thriving family physician making a difference, making health IT work for her and her patients. Can we all do the same?

Carl Olden, M.D., is a member of the AAFP Board of Directors.

Comments:

The problem is not EHR or digital technology. The problems with technology occur when they exceed their limitations. Perhaps what bothers physicians the most is that they understand their limitations and the limitations of the technology that they us - but those who design health care do not. The Managed Care to Dartmouth to ACA to MACRA result has been staggering. There has been a crippling increase in the cost of delivery plus a crippling of the team members to deliver the care - an unprecedented one-two gut punch for health care delivery. The designers wanted to change physician behaviors (micromanage) using digital technology. They do not understand that you make changes by supportive rather than punitive approaches. Physician behaviors under the assault of these out of touch designers have been changed away from patient focus to withdrawal, disengagement, turnover, and other wrong way behaviors. The right technology finds a way to the right uses and avoids abusive uses - such as team member productivity compromise. The designers have pushed technology too far and too fast and despite known limitations such as cost of development, cost of maintenance, cost of updates, security gaps, and privacy issues. Numerous wonderful examples can be dredged up of complex patients - but most Americans hardly utilize health care and a good portion remaining use very little - yet all have had to pay dearly now and for years to come. Where technology supports care delivery, it should be advanced. Where it impairs care delivery and the team members to deliver the care, it should be allowed to fall by the wayside. The Ecology of Health care that has become so important to family medicine, should be applied to what we support or not. Our patients the opposite of the current design directions - more team members, more productivity from team members, and more time and effort to address behaviors, situations, environments, and other people factors. These are the route to address 60% of health outcomes - a stark contrast with the digital clinical interventions that might shape a few percentage points at best.

Posted by Robert C. Bowman, M.D. on October 12, 2016 at 12:54 AM CDT #

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