Tuesday, April 29, 2014

Vertical Integration of the Electronic Health Record

After reading multiple articles on the pros and cons of the Electronic Health Record (EHR), it is crystal clear there are multiple competing forces on the utility of the EHR.  These can be divided into five-factions with their independent, but often conflicting needs.

Their needs and desires are #1-10; the pursuit of data.  This data will be used to create health policy that will theoretically control costs.  The key to controlling costs will be behavior modification.  the most expensive item in medicine used to be the pen, but it is now the mouse click where multiple clicks can easily spend large amounts of money.  Behavior modification comes through the endless "carrot and stick" approach.  Meaningful use monies (a huge driver in the rush to adopt EHR systems with the fear of claw backs are classic tools of situational bribery.  The move to ICD-10 and ePrescribing are more attempts to capture more data.  The positive side may be the development of the ACO's (accountable care organizations) that will pay on performance.  How this will occur in reality remains to be seen.

Their need is based on getting "paid" under the ever increasing burdens of unpaid government mandates.  The institution need records that obtain the meaningful use money, core value reimbursement data, and sophisticated billing strategies to obtain any and all available funding.  The hospital's bottom-line drives the purchase of the EHR and mandates that the employees and providers conform to the EHR work-flow paradigms rather the more logical reverse.  This puts more demand on providers and staff without the positive team approach feedback.  The end result is chronic dissatisfaction, reluctance to embrace the "future", and decreased productivity.  The hospital attempts to use the EHR to control behavior and outcomes are not working to well.  Computer driven paradigms can assist, but cannot control the complex interactivity between multiple providers and staff.  The hospital also has not taken into account the "cost of clicks" and by making the provider the de-facto ward secretary has led to poor productivity.

Third-party payers
Insurers have a keen interest in the out-workings of the EHR.  Not only will their data - see government- be therein contained, but also their actuarial statistics that allow determination of premiums, profits, and thus survivability.  All three of the other parts of the pyramid are balanced on the payer, and these entities are in the very middle of the mix.  Every one of the other factions relies on the payers to keep the balance.  It is an uneasy reliance at that.

The clinician wants a program that works for them.  This means the program must be developed from the user's point of view not the computer programmer or organizational views.  This means that the needs of the operating room are different than the Emergency Department.  A program with a strong central backbone that integrates with various products designed specifically for that area is desirable.  The user wants walk-up usability (no need for endless training and retraining), easy navigation, crisp interfaces, and easy access to nursing notes, old records, and ancillary service records.  The user wants a cost-benefit analysis of the elimination of the "classic" ward secretary leaving the providers to fend for themselves with minimal support.  The providers should be supported rather than given more "data entry" tasks.  When overall productivity go down and meaningful use money disappears; making the provider more efficient will make the organization more money.  The user wants clinical decision support (Artificial Intelligence), but with a "soft touch" not a hammer.  This will help with malpractice, billing, and ACO support.

The patient, or should it be said "and then there is the patient..."  Usually the most forgotten in the mix, but also the most important, the bottom line, the raison d'etre for all the others.  Why is the hospital erected, the provider well-studied, the government interested, or the insurance company calculating, if not the this central, key entity...the patient.  More and more, EHRs are actually allowing patients within a system to have certain forms of access to see results, and report status back to the clinicians.  Keep in mind though, if the patient's are not happy...think: long waits, errors, incomprehensible documents...it ain't gonna work.

Bottom-line is the needs of all groups are important, but by enlisting the player who is really the quarterback (the end-user clinician, physician) as a champion, calling the plays calling the shots, one has the best organizational team for success.  By vertically integrating the Electronic Health Record and providing the needs of all five silos, with one quarterback, the EHR will be gladly accepted and not create so much angst.

Monday, April 21, 2014

Cultural Equivalents in Standard Greetings

After taking yoga for more than a year and hearing the word "Namaste" multiple times, it reminded me of the Hebrew word "Shalom, the Arabic word "Assalamu alaykum, and the Hawaiian word "Aloha". 

Namaste is a customary greeting when  individuals meet and a farewell when they part.  It is a form of greeting commonly found among people of South Asia, in some Southeast Asian countries, and diaspora from these regions.  Namaste is spoken with a slight bow and hands pressed together, palms touching and fingers pointing upwards, thumbs close to the chest.  This gesture in Hinduism means "I bow to the divine in you".

Shalom is a Hebrew word meaning peace, completeness, prosperity, and welfare and can be used idiomatically to mean both hello and goodbye.  As it does in English, it can refer to either peace between two entities, or to the well-being, welfare or safety of an individual or a group of individuals. 

Assalamu alaykum is an Arabic greeting widely used in the Muslim world even by non-Muslims.  It nearly translates to "peace be upon you", but is often considered the equivalent to "hello", "hi", or "good day" in English.


Aloha in the Hawaiian language means affection, peace, compassion and mercy.  Since the middle of the 19th century, it also has come to be used as an English greeting to say hello and goodbye.


One could go to every culture and find a similar sentiment.  The bottom line is that fundamentally everyone is the same.  When it comes to the preliminaries of human contact, at least at a fundamental level underneath the difference within language. 

However, in the ED, the key challenge is putting the patient/family at ease in a matter of seconds.  There is really not much time to accomplish this, and following a few basic principles goes a long way.  Here are some:
  1. Eye Contact-Confidence: Put the patient at ease by looking them in the eye, and having a bearing that reflects confidence.  This gets the patient over the initial anxiety hurdle of winding up with a less-than-fully-competent physician by allowing them to say to themselves "this doctor knows what they are doing".
  2. Advance Knowledge: Put the patient at ease by knowing something about the case before you walk into the room, and showing that in your initial words.  Asking "why are you here" is a loser... because the common answer or thought is "I've already told five people why I am here!"  How much better to walk in and say "I understand you are here, because you are having XYZ (chest pain, weakness, shortness of breath, etc.) .
  3. Common ground: Put the patient at ease by establishing common ground from the get-go.  An initial "I understand you are here because..." starts that ball rolling, and following that with some reflection on their discomfort or anxiety, will enhance the encounter tremendously.  You might say, for example..."you must be feeling pretty bad to come here to the ED, it is hard to come into any medical facility, and I'd understand if you felt anxious or worried".
  4. Outline of Plan: Put the patient at ease by giving a quick summary of what you are going to do to help.  EG: "Well, we are going to help you feel better...first we'll relieve pain, alleviate distressing symptoms...then we will run some tests to find out why this is happening...and then we will do whatever we can to help you.
  5. Questions: Put the patient at ease by now...starting your actual...interview..."So...let me ask you a few questions..."


Monday, April 14, 2014

10 Things Medical Records Won't Tell You!

The Wall Street Journal published an article last week on the 10 things medical records won't tell you.  I have condensed the list, so you get the idea...

  1. COST: The price tag is HUGE!
  2. SHARING IMPORTANT CLINICAL INFORMATION between providers is a myth.  Even high-price tag enterprise level systems do not do this well, or cannot, especially between different hospitals and doctors.
  3. DOCTORS HATE IT in general and pretty consistently, especially if forced to use it by their hospital, the government, or partners.
  4. DOCTORS HAVE LESS TIME to spend with patients...because they have to fiddle with machines.
  5. PRIVACY physicians may employ strangers such as scribes to manage there cumbersome EHR into the previously sacred and secure doctor-patient relationship.
  6. ERRORS MAGNIFIED mistakes are easier to make; just hit the wrong key, or have a voice recognition system hear "no chest pain" instead of "known chest pain".
  7. INFORMATION OVERLOAD TMI- too much information...sometimes, in fact most of the time, we just don't need or want to read "War & Peace" on every patient, and only a section of the total is needed in any clinical situation.  But the EHR commonly gives it all. No one, especially not clinicians, have the time to read it.
  8. IDENTITY THEFT EHR's contain much of your demographic information--social security, payment, address, phone, work schedule, etc.  They are therefore a fertile ground for the thieves that prey on such things.
  9. YOU BECOME A MARKETING STATISTIC your information will be marketed and sold e.g. to pharmaceutical companies, insurance companies, etc.
  10. BIG BROTHER IS WATCHING the government can and will track the events that occur in medical interactions through EHRs.  The requirements and criteria for this sort of tracking are already in place.
Choose an Electronic Health Record that has thoroughly considered these complaints and actively deals with them.  Complaint #10- government policies and incentives is the biggest driver in turning to EHR.

Wednesday, April 9, 2014

Avoiding the Malpractice Trap

Malpractice is back in the news with the Florida Supreme Court ruling that non-economic caps are unconstitutional.  In California, the cap will probably be adjusted to cost of living increases making it at least $1,000,000 for pain and suffering.

With the affordable care act putting more financial pressures on providers, not dealing the malpractice issue at all will lead to higher costs inevitably.  One main reason malpractice claims in two high risk states like Florida and California were semi under control - it is too expensive for lawyers to take on marginal cases.  Marginal cases equal low potential return on investment (ROI) regardless of the facts.

The trick is never getting named in a lawsuit.  Even if you win, get dropped, or the case is not formally pursued, there are still legal fees and emotional distress.  Providers are instructed to view malpractice as a cost of doing business, but most people cannot separate business reality from a very personal attach on their core identities.

Suggestions to stay out of trouble that do not include more tests or defensive medicine.
  1. Keep well informed about trends.  Risk Management Monthly (no financial ties) does an excellent job.
  2. Be aware that the patient is judging you on punctuality, and feels their time is just as important as yours.  A good strategy is to always apologize about the wait time even if you are early.
  3. Introduce yourself to the patient and their support team.
  4. Find out what brought them in today aka motivation for the visit i.e. wife insisted, worried about a stroke, death in the family, etc. Responding to their pressing need eliminates the provider didn't listen to me!
  5. Allow the patient to speak for at least 60 seconds before the cross-exam begins.
  6. Use the data other people have collected by confirming, not by asking the same questions over and over.
  7. Verbalize the battle plan and make an estimate the time frame.  If possible, have your staff in the room for this, everyone is aware of the plan.
  8. Check on the patient to see 1) if their pain or comfort has been attended to and 2) to give an update to the progress of the plan.
  9. Do not tell jokes.  The patient is not sure if you are laughing with them or about them.
  10. Use shared decision making, if appropriate.  Critical patients and their support team want to be consulted.
  11. Give the patient very specific follow-up directions with specific time durations.
  12. See a patient in a recheck as a second opportunity to get it right.
  13. Document a clinical course and important conversations with patient, family and consultants.
  14. Be aware of the limitations and positives of your documentation system.  Remember all entries are time-stamped.  Explain why the EKG was recorded being read at 14:00, but was read at 10:00 , especially if clinically significant.
  15. When patients disagree with you and want to leave against medical advice, it behooves you to personally come to an agreement on the situation.  Delegating to a staff member is a huge error.  Make sure the patient knows they can always comeback, have witnesses especially their support members in the room, and give appropriate prescriptions for needed therapy.
Avoiding being named is the key to success.  Following common sense protocols does not increase time spent, but actually speeds up process because the patient and their support team are informed.  People sue because they are mad or frustrated.  They usually cannot determine quality care, but they know how they feel about you.

Wednesday, April 2, 2014

Rethinking Office Personnal

Rapid change is occurring to the world of medicine and its varied practitioners.  These practitioners run varied practices, but all have the similar goal of providing quality health care.  The trick is figuring out how to change your processes to reflect the new nature of health care.

Traditional practices have office managers, receptionists, medical assistants, nurses, technicians, and the various providers.  As technology and new rules come into play, these various roles will need to be adjusted.

All the employees of the business will have to be able to multitask, be cross-trained, and most of all pleasant.

The receptionist will be a self-logging user-friendly computer terminal similar to the airlines where the consumer logs in with drivers license, credit card, insurance card and eventually their own personal barcode.  The computer will access eligibility, account balances, and create a spread sheet of what the patient is covered for, their referral list (specialists, lab, x-ray, and needed age-appropriate wellness screens.  The computer will ask pertinent information of the patient pertaining to the chief complaint and motivation for visit.

The intake specialist will review the data, while the vital. sign machine records the blood pressure, etc.  They will order obvious tests (blood, ekg etc. per protocol) and queue the patient to the appropriate provider according to triage protocols.

The provider (Physician, Nurse Practitioner, Physician Assistant) will assess the patient, determine a plan, institute a protocol if needed, and/or make a disposition.  Their personal data technician will create a document that reflects the transaction and document the orders.  The provider may want to input some data through voice-activated technology.  The nurse, medical assistant, and technicians process the orders.  The data technician advises the providers about alerts, core measures, etc. that the Electronic Health Record has given a notification for.

After the patient is given their instructions and medical education by the provider or their surrogate, the social worker interviews the patient.  They deal with the most difficult part of the transaction.  They advise the patient within their social situation how to access their prescriptions, follow-up care, and devise a real-time follow-up plan to keep the patient from floundering in confusion.

The billing specialist analyzes the visit and informs the patient of the costs and options.  With modern billing technology, most practices will be able to do their own billing.

With the social worker monitoring the care in real-time, this should lead to consistent, cost efficient outcomes.  The provider with this type of cross-trained medical staff can hopefully concentrate on practicing "Medicine" and not business, liability, and endless outside pressures.  This environment will lead to success and job satisfaction for all parts of the team.