Posts Tagged ‘electronic health record (EHR)’

Electronic Health Records & Medical Scribes

Wednesday, February 5th, 2014
Turn over the data entry to someone else, doctor.

Turn over the data entry to someone else, doctor.

Recently, in the online version of The New York Times, I saw an article by Katie Hafner titled "A Busy Doctor's Right hand, Ever Ready to Type." The article described a new movement among medical personnel, one to hire scribes to make entries into an Electronic Health Record (EHR).

The concept made great sense to me, but it's clearly not a new one. Our ophthalmologists have, over the last fourteen years, routinely had an assistant who entered data into some form of a medical record, allowing the physician to concentrate on examining us.

Only five years back the use of an EHR was clearly the exception for other medical personnel with perhaps a tenth of physician office practices and hospitals utilizing them. now that percentage is well over two-thirds.

So what are the problems with universal acceptance of EHRs?

One that I touched on in my previous post on EHRs is interoperability between different health-record systems. My translation of that term is that Dr. A using, for instance, Epic at a UCH site like our local hospital, should be able to access and read my medical record from the Department of Defense or the Veteran's Affairs' systems. At the moment I doubt that's even remotely possible and there will obviously be issues with patient confidentiality. Those should be eventually solvable, although the mechanism for doing so is well beyond my computer skill level.

But, for an individual practitioner, on a day by day patient-care basis , there's an entire other set of issues.

I had mentioned in a recent post our pleasure at watching a Family Practice intern who kept eye contact with her patient (in this case my wife) while she examined her and informed her about test results.

The intern wasn't entering data and there's the rub with an EHR. She presumably had the choice of doing her examination and keeping as much eye contact as possible with her patient while remembering all the accumulated data points versus typing while she asked questions and, if she were a typical doc typist, looking at the keyboard and the screen much of the time.

The opposite end of the spectrum was a nurse who, in order to give Lynnette an ibuprofen tablet, spent twelve minutes (I timed the interaction) between my request for her pain med and it being put in her mouth, mostly on the computer, occasionally glancing up to ask a question (e.g., "On a scale of one to ten, what is your pain level? What is your full name and date of birth?{the fourth time she'd asked that during her shift}).

As the EHR has grown more complex, with more mandated information being necessitated by organizational, certifying and governmental entities, the potential for increased human-machine time has grown hugely, while the doctor-patient segment of a physician's day is squeezed.

The potential for burnout of physicians, especially in emergency medicine, family practice and primary care internal medicine has increased. The link is to a free article that appeared in the Archives of Internal Medicine in 2012 comparing both burnout and satisfaction (with physicians' balancing work and outside life) to others in the United States. Bottom line was of the 7,000+ docs who filed in a survey, over 45% had some symptoms of burnout and were much less satisfied with their ability to find a counterpoise between their work time and the rest of their life than those with comparable professional degrees.

Burnout meant less enthusiasm for work, development of cynicism and less of a sense of accomplishment than those of us who practiced medicine years ago had. There are lots of components as to why this has become more common among "front-line" physicians, but as I've talked to some recently the EHR has been a very significant contributor.

This was a somewhat unexpected development for me, although based on what I had seen with my radiologists attempting to dictate into an earlier version of an EHR in 1988-1991, not one that I  should have been surprised by.

Adding one more to the medical team should be easy.

Adding one more to the medical team should be easy.

There is a growing industry providing medical scribes to physicians and others and, since 2010, certification available through a non-profit, the American College of Medical Scribe Specialists. I was somewhat surprised that patients not only haven't objected to a scribe being present, but often have warmly welcomed them. They may be introduced as "my data entry specialist." Obviously, in teaching hospitals, patients see a team of physicians already. Only the most intimate parts of a physical examination would need to be conducted in a one-on-one basis. Then the scribe could be on the other side of a curtain and the doctor would verbally describe her or his findings.

If I had the choice of my physician looking at me almost all of the time and, in essence, dictating her findings (my own doctor is female) or having to type much of the time, my choice would be simple.

Then there's the possibility of a remote scribe. I had envisioned a future EHR which had set areas to be filled in and a practitioner being able to wear a headset and dictate into the EHR directly. I hadn't realized that some practices already have scribes who may be thousands of miles away from the patient-physician encounter, sometimes in India.

I went back to the New York Times article I mentioned initially and saw a quote from a family medicine physician who said, "Having the scribe has been life-changing." An article in the journal Health Affairs said two-thirds of a primary care doctors time at work was spent on clerical duties that could be done by others. Another doctor  said, "Making physicians into secretaries is not a winning proposition." She had surveyed over 50 primary care practice in the past five years, finding those who used scribes were more satisfied with their work and their choice of careers.

Doctors have been dictating patient records for fifty years, but those transcriptions often made their way to the chart many hours later. Having a scribe could cut that lag time immensely.

With our growing need for primary care physicians and the tendency for medical students to avoid those specialities, aiming toward more financially rewarding and less laborious fields in medicine, the advent of medical scribes may be not only a significant improvement for the lives of those already in front-line medical areas, but an inducement for new prospective physicians to join their ranks.

I'm heartily in favor of the idea.






Electronic Health Records: Conquering a major "con"

Saturday, January 18th, 2014
The question is how to connect the two.

The question is how to connect the two.

My first electronic medical record encounter was in 1975 at a not-for-profit hospital in California. I could enter orders for my dialysis patients and retrieve lab test results. I thought it was" better than sliced bread." I don't remember any negatives about the system other than not being able to connect to it from the private medical office I shared with another nephrologist. So there were lots of "pros" and no major "cons" as far as I was concerned.

Of course, it wasn't a complete Electronic Health Record (EHR) and I couldn't dictate the results of a physical exam or anything else into the system.

In mid-1988 I became the commander of a small Air Force hospital in Texas that was a test site for the Composite Health Care System (CHCS), a  Department of Defense effort to have a system-wide EHR. During the preceding six months, when I had been the deputy commander, I was aware there was a rudimentary system in our x-ray department, one that let our radiologists dictate a report. But they had to speak slowly, in an absolute monotone, for it to work.

I attended my first CHCS meeting, with the Assistant Secretary of Defense for Health Affairs (ASD/HA) and all three military Surgeons General seated at the front of a large room. CHCS had morphed into an endless series of blah-colored screens that my docs, nurses and other medical personnel could use to retrieve and enter patient data. At that point I thought it was an elephant designed by committee, a prototype that had a long, long way to go before it was a viable EHR.

I was the junior commander in the room, having been a bird colonel for only three years. Many of the others were long-time colonels or one-stars and even, in a few cases, two-star generals/admirals. After a few introductory remarks, the ASD/HA said, "Colonel Springberg, you're the new kid on the block; what do you think of CHCS?

All eyes turned to me and I blurted out, "Frankly, sir, I think it sucks."

Shocked silence for a moment, then he asked, "What do you mean?"

"My docs hate it, sir. It needs to have a touch-screen or a mouse-able interface or be on a Mac with some colorful screens. As it is, there's row after row of green lines of questions that can easily put you to sleep."

I survived that meeting (perhaps just barely) and my own Surgeon General showed up in my office back in Texas a few weeks later. That wasn't unusual, as he fairly frequently came to the base for events at the Medical Service Training Wing and stopped to talk to me on the way. This time I was concerned he'd want to chastise me for my remarks.

"Peter, do you remember that CHCS meeting?" he asked somewhat rhetorically. "Do you remember what you said?"

My heart skipped a beat or two.

"Well I agree with you. I just can't say those kinds of things. Keep it up!"

Twenty-plus years later, DOD was still using a version of CHCS for healthcare administrative purposes and had something called AHLTA (the Armed Forces Health Longitudinal Technology Application; DOD does love acronyms) as its EHR.

Then in May, 2013, the Secretary of Defense announced a plan to replace AHLTA with a commercial EHR with a short-term goal of coordinating with Veterans Affairs to "develop data federation, presentation and enhanced interoperability."

After I looked up the term "data federation," it made sense. We're talking about software allowing an organization to use data from a variety of sources in a number of places with the data itself remaining "in the cloud."

If you're speaking about medical records for people who move around the globe and often later stay in an allied system (the VA) after they retire, it would be great to be able to access all or part of an EHR without the need to move physical patient charts.

Then how do they find my old medical records?

Then how do they find my old medical records?

I've got part of my old military health record sitting on a file cabinet in this room, but what I really would like is for all my records to be accessible to any doc I see. whether it's my own ex-Air Force Family Practice physician here in Fort Collins, someone at a VA clinic I might happen to stop at on a trip, or a civilian doctor in Canada or Europe I see in an emergency room

My left shoulder has been painful for six weeks. I saw my physician, got a referral for physical therapy and drove nearly twenty miles to see the PT who works for the local hospital chain (now a part of the University of Colorado) and was moved sometime back to an outlying location. She's really good, so I became one of her groupies, patients who, when they need physical therapy, decided they'd follow the PT they liked best.

If I were still on active duty (it's been nearly sixteen years since I retired), she might have been sent to Italy or Guam. But twenty miles was doable.

After her usual thorough exam she started entering data into a computer. Epic, the EHR used by University of Colorado Health (UCH) meets the 2010 Patient Protection and Affordable Care Act standards, was adopted at the main UCH hospital in Denver in 2012, reached the affiliated northern Colorado hospitals and clinics in July 2013, and will extend to other UCH locations by mid-2014. So if I'm seeing a practitioner at any UCH location, they can pull up my EHR onscreen. 

There's now a non-profit Healthcare Information Management Systems Society (HIMSS) an organization that was formed with goals to improve healthcare through information technology. As I thought about the issue on the way to the gym yesterday, I realized one problem is defining who can see my medical data.

Medical data privacy is crucial to many and my first thoughts along this line were rapidly discarded. I don't want Joe Ripoff in Otherplace, Elsewhere, to easily access my records and couldn't initially think of a way  that all medical personnel anywhere could have easy entry to my EHR without some hacker also being able to duplicate the necessary passcode. And if I carried a card in my wallet, it could be pick-pocketed. Even if I had my own personal code, I might forget it or be unconscious.

Then I had an idea that could safeguard my medical record while allowing any practitioner I see while traveling to gain entry to all my stored records. It turned out not to be a new idea at all; others have suggested it for the last fifteen or so years.

My dog has an implanted microchip so if he's lost someone can scan him and find who he belongs to. I would be willing to have such a chip in, for instance the flesh of my arm, modified to contain my entire EHR.

If that technology would allow a medical team anywhere to scan my arm and then retrieve my medical data, it might be worth considering.

This sounded like science fiction, but apparently it's possible and it also caused a furor. I Googled the idea and found that had debunked the rumor that the Affordable Care Act mandated such microchips be implanted in everyone. Supposedly, according to the canard, the chip, about the size of a grain of rice, would also link to your bank account (It's not true.) However, an-EHR-microchip, while conceivable, has been resisted by some religious groups and by many who are concerned that they would lead to Big Brother government being able to track all of our movements. Some have even said the data would be accessible to anyone with a scanner.

I think those objections, except for religious ones, are a stretch. And the data could be encrypted.

So my level of paranoia on the issue being quite low, I'm ready for a microchip.

It should absolutely be your choice, of course, whether you get one or not.