The Right Click Dilemma!

What is the difference between a person who understands computers and the rest of us?  It is the ability to understand that programmers love to right click to create endless contextual menus.  these menus are interpreted by IT people because 1- they know they exist and 2- they read and act on these menus.  The rest of us stare in silence, stupidity, or disbelief.  How did they know"that"?  Why would they hide the menu from us?

When dealing with many Electronic Health Record systems, the right click is your arch nemesis.  You had endless hours of training, but still cannot remember what to do next.  You did not realize that you can right click something or everything and multiple hidden menus appear with the answer.  When you have suffered through multiple minor epiphanies and created multiple "work-a-rounds" and/or "favorites" the program becomes less onerous.

The real solution is end-user friendly Electronic Health Record do not rely on a right click, multiple hidden menus, work-a-rounds, and favorites to utilize.  The user should be able to look at the screen and intuit what to do next.  What is painfully obvious to the "programmer" is not obvious to all end users.

If the program takes endless hours of training, needs "super-users", and you forget things after only 1 week, the endless psychological toll it takes on the users is profound.  This leads to lost productivity, unhappy employees, and general disenchantment with the whole process.  The Electronic Health Record has many potential benefits, but this is often lost in the battle to process efficiently.

Artificial Intelligence

Artificial intelligence (AI) is the intelligence of machines-robots and the branch of computer science that aims to create it. AI textbooks define the field as "the study and design of intelligent agents" where an intelligent agent is a system that perceives its environment and takes actions that maximize its chances of success.  Wikipedia defines it as "the science and engineering of making intelligent machines."

 

One of the greatest values of the Electronic Health Record is the seamless addition of AI to the user’s own brainpower. This is manifested in various ways.  Below is a list of potential AI elements, some already present to some degree, in various systems:

1. Drug interactions 
2. Drug Allergies 
3. Recommended “state of the art” treatment plans when a sign, symptom, lab result, x-ray results, EKG data, evaluation of PMH, SH,FH, working diagnosis are noted by the computer. The computer does a risk factor analysis of the data and creates a differential diagnosis. 
4. Warnings --
1. Errors in dosage 
2. Errors in medications 
3. “Are you sure you want to discharge this patient” with this constellation of data points? 
4. Wrong patient-in congruent data entry 
5. Reminders -- 
1. Lack of documentation completion 
2. Lack of signatures 
3. Attention to attestation of information 
4. Core measures, PQRS, on-going studies  
6. Active rather than passive resource tool 
1. Who’s on call 
2. Phone numbers 
3. Timing of interactions of consultants/i.e Cardiology consult might be beneficial 
4. Recommend evidence based resources or wed sites if more info is needed 
5. Calculates various scores (Glasgow Coma Scales, PERC score, TIMI scores) that are clinically relevant
7. Feedback --
1. How much money did you spend to attain this end-point? 
2. What was clinical outcome of admitted patients? 
3. Report on rechecks and bounce-backs 
4. Admission rates 
5. Times-LOS, door to doctor, doctor to decision 
6. Benchmarking your performance within your practice, local hospitals, and national data

The addition of AI should be embraced not avoided. Theoretically, it could make your difficult job less stressful and more efficient.

However, one should always keep in mind the meaning of the words “artificial” and “intelligence.”   These do not inherently include the terms “wisdom” or “judgement,” the standards a physician is always held to, medically and legally. Thus a physician has the obligation to accept or reject the advice of the machine. In either case, the physician is ultimately responsible. While we are not yet confronted with the independence of the computer, as depicted by Hal in Stanley Kubrick’s 2001 A Space Odyssey, one might best remember that it was astronaut Dave who disconnected Hal’s power supply to save his own life. We may, at times, need to do the same.

Prolonging Your Career!

Recently I have been unable to work full-time due to medical issues.  However, it is not due to any chronic or underlying condition i.e. DM or CAD, but to a relatively sudden onset musculoskeletal breakdown.

If you saw the overweight, balding, shuffling, poor posture, and moving slowly provider, THAT WAS ME!

It has become apparent to me, that proper physical conditioning is an absolute requirement for our busy, stress-laden jobs that require of us 5 miles of walking per shift.  I worked out in a linear fashion i.e. elliptical, treadmill, and stationary bike 3-4 times/week faithfully for at least 1 hour sessions.  This did not prevent my problems.

I went to the orthopedic specialist for help with this new issue, and the first thing he recommended was taking up yoga to loosen up my totally “stiff body”.  First attending “restorative yoga” (geriatric yoga where touching your toes means reaching your knees), it was apparent that I should have been doing something like this for years.

After 2 sessions, I could now back up car safely without the use of a camera display or grab things out the back seat easily.  The classes are difficult, but improvement comes with each one.

Everybody worries about their mental health, brain power, medical health but musculoskeletal breakdown needs to be added to the list.  Yoga is a good path; some do Pilates, some intensive stretching; in any case, paying attention to, and managing, muscular flexibility and mobility is key in our profession.        

 

Which EMR Should You Purchase ?

CRITERIA:

1. Certified for meaningful use to offset costs-(includes easy reporting functions to avoid government "clawbacks".)
2. Walk up usability-(the ability to perform various functions with minimal training)
3. Intuitive navigation-(logical, consistent, and labeled)
4. Content designed specifically for the clinical area (specific charting for the Emergency department, urgent care, and/or family practice)
5. Integrated practice management - (scheduling, coding, and billing)
6. E-prescribing
7. Patient Health record (clinical data repository) that tracks Problem list, Allergies, Past Medical History, medication reconciliation, Family History, Social History
8. Ease of training-(3-4 hours vs  longer than 12 hours)
9. The program does not need multiple "work-a-rounds"
10. The use of scribes and voice-activated technology are additive,not necessary to survive

This is the tip of the iceberg. Bottom line, is purchase a product that is designed with the " End-User" in mind.

Practice Management - Requirements For Success

Many individuals are inspired to become entrepreneurs and control their own work destiny.  They are willing to put in the “sweat equity” to be their own ‘boss’.  Opening and running your own practice and or urgent care is a worthy goal but to be successful, the “devil is in the details”. 

Here are some suggestions on how to select a “value added” practice management program that allows one to run an efficient business.

1. Attractive interface that has “walk-up” usability
2. Designed for end-user not programmer
3. Easy, logical navigation
4. Scheduling module that can be customized 
5. Registration module with scanning of  identification and insurance cards capability
6. Instant eligibility notifications for insurance, deductibles, and co-pay
7. Instant access to past visits and  accounts receivable
8. Fully-integrated Electronic Health Record that interacts with the practice management system to capture all CPT codes, ICD-9-10 diagnosis to easily code and send an accurate bill.
9. Certified Electronic Health Record to be eligible for $44,000 meaningful use funds to defray initial costs.
10. Electronic Health Record that has a full database, scanning capabilities, E-prescribing, and is not “hated” by the end-user.
11. Coding support and billing functions that allow you to 1. Do your own billing 2. Outsource to a billing company 3. Any combination of the above.
12. Gives real-time feedback on AR to allow staff to resubmit claims for reimbursement in a timely manner
13. Management reports
14. 24 hours support
15. The cost of the software is offset in savings in the number of FTE’s (full-time equivalents) to run the practice.

Every practice is different, but being efficient and controlling costs goes a long way toward a positive ROI (return on investment).

“Resistance is Futile”

Since the Luddite ‘s anti-technology movement in the 19^th century in response to the industrial revolution, modern technology has been not always welcomed with open arms.

Fear of change and the inability to cope with new processes make the  end-user feel like nobody is listening to them.

The Electronic Health Record is a good example of forcing a one- size-fit-all solution to complex processes that are not all linear, obvious, or easy to categorize.

It throws another obstacle at the end-user already who is already burdened with endless multitasking, interruptions (some important and critical), time concerns, and living up to quotas.

There are solutions:

1.     “Best of Breed” computer programs for various departments that integrate with the monolith ENTEPRISE SYSTEM.  IT people all want one program to make it easier for them. They are not the customer.

2.     Use of various platforms that individual providers can use to accomplish the same goals.

3.     Listen to the END-USER. The owners of the institutions and the practice will be rewarded with increased productivity, safety, and net revenues.  Job satisfaction will be increased and burnout will be delayed.

4.     The Russian space writing utensil (the pencil) may be the best solution instead an exotic, complex solution.

For the Luddites in the audience---embrace technology but with the caveat that common sense, simple solutions are the best.

In the end, technology should exist help - not create “work-arounds” to fit square pegs in round holes.

Changing the Paradigm for Outpatient Care

The present model has the primary care physician as the provider and gatekeeper of patient care. They evaluate the patient, obtain consultation, admit to the hospital (the hospitalists have taken over this role), and are the general coordinators of care. However, this model in theory works well; it has proven to be ineffective. This is no criticism of the concept but the complexity of modern medicine has made this very difficult for the average family practice unit.

Current Model

The family physician is supposed be the “gatekeeper” of resources and keep people out of other venues like Emergency Departments and urgent cares.

The problem is that the general public has voted “with their feet” that they prefer the family doctor when they are well, but the Emergency Department when they perceive themselves to be quite ill and the urgent care for quick, convenient care.  Call any doctor’s office and the first non-human response is: “If this is an EMERGENCY call 911 or go to the nearest Emergency Department.”

At the present time Emergency Department Services comprise approximately 2% of the nation’s annual healthcare expenditures.

Almost every ED has the built-in infrastructure to accommodate large number of patients which could be expanded. These are centrally located in most communities and already are the de facto safety net of the United States.

Make the ED the central piece of an organized system of emergency department, urgent care, family physicians with an integrated use of consultants.

New Model

Advantages are:

• Lack of duplication of hard assets
• Patients already prefer the ED
• Coordination of care