A Blast from the Past!

In December of 2012, we posted the Changing Paradigm for Outpatient Care blog.  Reading through Emergency Medicine News latest February 2015 magazine this afternoon, I found a blast from the past!  The Special Report: ED as Hub of Healthcare discusses why folks go to the emergency department for health-care.  Read both the article and the blog post below for some insight.  Enjoy!


December 3, 2012: The Changing 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

Using the Electronic Medical Record as a Teaching Tool

Tech-savvy first-year medical students are staying one step ahead with an EMR system.  The electronic medical record is charting a new course by including as part of the medical curriculum.  The potential added-value is relevant to medical students, nurse practitioners, physician assistants, and physicians. 

The electronic medical record can guide one through the assessment of the patient by creating a back-round of appropriate questions to focus in on the problem.  The record can theoretically provide the necessary historical information to aid in the diagnostic and treatment process.

An EHR can list red flags, risk factors, and warnings about potential high risk diagnoses related to any chief complaints.  The EHR can provide clinical assistance through warnings of drug allergies, drug interactions, and potential treatment plans.  It can also provide medical liability protection.

The EHR can link in real-tie with outside data sources to provide real-time comprehensive information.  Artificial intelligence that provides clinical guidance and support is in its infancy, but will someday be available. 

How can you take advantage of these features?

1. Find an EHR designed with the end-user in mind.
2. Determine whether the documents are outlines or sophisticated content designed to assist the provider.

A sophisticated clinically useful EHR can aid providers at all levels, training or experience.  Teaching and learning is a life-long process.

Emergence of the Electronic Scribe

The definition of a scribe is a person who writes books or documents by hand as a profession ad helps keep track of records.  This profession is found in all literate cultures and lost most of its importance with the invention of printing press. 

The modern medical scribe is more a data jockey than a hand writer.  With the advent and proliferation of the Electronic Health Record (EHR), providers are forced to add more people power to document their records.  Originally most records were handwritten and/or dictated.  The downsides of handwriting are illegibility, incoherence, and lack of completeness.  Dictated report are often incoherent and filled with mistakes.

The EHR solution where the provider would type organized, logical data collection giving the document a realistic reflection of a clinical interaction. 

This assumption unfortunately does not translate into the reality of time constraints, lack of computer skills and difficult user platforms.  Providers became data entry clerks and charts are written in "computereeze".

Administrators and providers needed solutions.  Thus was born the medical scribe- an ancient Egyptian worker to document the history of what was happening.  Scribes follow the provider and inputs data into the EHR.  In lieu of using a scribe, voice activated technology.  The provider can dictate key information directly in the EHR.  Both of these solutions still have down sides such as incoherence and providers lack of computer skills, but are better than the third option of overtime typing/clicking everything yourself.

The negatives of scribes are costs, potential lack of accuracy during the filtering process and fundamental distaste of hiring more people to function normally.  EHR technology was meant to simplify the process, not exponentially complicate it.  The creation of the EHR has also created an unfunded mandate to provide more information to the government with the goal of solving human interactions by computers.  Computers are tremendous assistants, but rarely solve interpersonal relationships with multiple variables like provider patient interactions.

Scribes have evolved into "clickers of data" and probably do not handwrite anymore.  There should be a better solution in the modern era.

Medical Scribes, Voice Activated Technology and the EHR

Back by populate demand.  The newswires have been blowing up lately with article about medical scribes and data governance.  A good article to reference this issue is Will Medical Scribes Limit Innovation in HIM, EHR Documentation?  It addresses the rise of medical scribes, EHRs, health information management (HIM) and data governance.  Take a look at the article and re-read the blog from 2013 written on the subject.  Enjoy!

 

 

 

This is an interesting problem with strong advocates on both side of the equation.

After going to the recent ACEP conference, it was apparent that scribe companies are coming "Out of the Woodwork" to offset the labor intensive enterprise Electronic Health Records being imposed on most emergency departments.  Scribes cost approximately $12 - $18 per hour each.  To offset these costs, the provider must see 2 - 3 more patient per shift.  At this point with a general reduction of 20% of productivity per provider, this is not happening overall.  Providers are struggling to stay even.  In institutions where a scribe can function as a medical assistant, a "Go-For", data acquirer from the old medical records, interact with the patients, and print discharge instructions and prescriptions, the extra work is a plus.  This is how most urgent cares function with an all-encompassing medical assistant with multiple roles.  In institutions where the scribe just inputs what the provider states, they are expensive transcriptionists and typists.

Voice Activated technology is an extremely efficient alternative to transcription at much lower overall costs. The provider can dictate key components of the history of present illness and the assessment and plan- medical decision making sections of the records.  This creates a unique non-cookie-cutter chart which helps the private MD, consultants, and your own colleagues, if the patient returns for follow-up.  The problems come in where the EHR is not directly designed without a lot of work-arounds to allow easy dictation.  The initial cost is $1,500 per provider, but transcription costs $7 - $8 chart and the money is regained in time with increased productivity.

Which one is recommended?  It depends on the work flow of the ED, the EHR, and the personality of the provider.  My personal preference is a user-friendly EHR and VAT, so you can take the savings to buy more physician assistant and/or nurse practitioner FTE's.  This hopefully will lead to increased throughput, higher revenues, and increased patient and administration satisfaction.  If my scribe is an all-purpose medical assistant, this would make a reasonable alternative.

Trying to Put the "Meaning" in Meaningful Use

High noon for federal health records program? 2015 will be a critical year for testing the system is an eye opening article.  Arthur Allen gives a critical analysis of the whole dilemma regarding the value of an Electronic Health Record (EHR) based on the present financial incentives.

The article explains the motivation of institutions to digitalize medical records, which primarily are two: money (potentially lost) and fear (of future penalties for not abiding by the complex rules the government has created).

Meaningful Use Objectives are defined in the chart below:

1. Improve quality, safety, efficiency, and reduce health disparities
2. Engage patients and family
3. Improve care coordination, population and public health
4. Maintain privacy and security of patient health information

Ultimately, it is hoped that meaningful use compliance will result in:

1. Better clinical outcomes
2. Improved population health outcomes
3. Increased transparency and efficiency
4. Empowered individuals
5. Robust research data on health systems

The intent of MU is good, but the reality is very different.  For one thing, "meaningful" depends on perspective.  That is, for a clinical user, meaningful is a different animal than it is for administrators, and for CMS, meaningful is a wholly different species.  Providers want usable data that supports direct patient care; they dislike having to capture endless streams of data for clinical irrelevancies.

So let's ask the following- since the bottom line is that everyone wants better care, what does a clinician find meaningful while providing that care:

1. Easy access to all relevant data in a recognizable format
2. Advisory alerts when appropriate
3. Clinical decision support
4. CPOE (computerized order entry system) that is universal and not totally provider driven- (Where have all the ward clerks gone?)
5. Insert your own here "xxx"

The government is looking for data to make political, cost, and cultural changes.  One unintended result is a new industry, a new unregulated "profession", medical scribe and that has certainly raised costs.  Along the same lines, CPOE has led to more tests, which equals more costs.

My suggestion is to read the article.  It does an excellent job of presenting the issues.  Ultimately, the solution is to create a national medical database that is easily accessible, secure, and agnostic as well as transparent to all EHRs, regardless of vendor or format.  With this database and a standardized CPOE, major benefits will be obtained.  Through the retrospect-o-scope, one sees that money could have been spent on this first; then the hospitals and providers would have clamored to be first to get an EHR that makes life easier.  As it is now, there is quite a mess to sort out with respect to interoperability and usability.

Where Has All the Interoperability Gone?

The entire meaningful use project intended to encourage provider adoption of Electronic Health Records (EHR), with the promise of easy access to patient records with two underlying goals: 1) improve the quality of health-care and 2) control rising costs.

Interoperability represents the ability of systems and organizations to work together (inter-operate).  Due to technical constraints systems often impose, the essence of interoperability in health-care has become, in essence, the need for easy, reliable exchange of information between these systems.

The EHR was supposed to interact with other EHRs to synchronize individual's medical history including tests and treatments.  Such synchronization in the US is important, as many patients wind up in different care settings.  This synchronization would give a care taker permission to all of the patient's clinical information.  This clinical data would be stored in a Health Information Exchange (HIE).  The HIE is defined as a mobilization of health-care information electronically across organizations within a region, community or hospital system. 

Although well-intended, the meaningful use program with its billions of spent dollars has further spurred the development of multiple competing health records that are by nature proprietary.  Enterprise systems, that provide the backbone of huge hospital systems are reluctant to interface with practice specific specialty "boutique" programs.  Why should these enterprise systems enable integration with boutique programs, when monopolizing their implantation over a hospital system is immensely lucrative for a vendor?  However, the reality is the boutique systems are often focused on end-user acceptance and walk-up usability, while enterprise systems--by their very nature, and especially by their hybrid, unfocused character--are unable to satisfy all end-users, if any at all.

How hard is it to interface through the HL7 standards developed for meaningful use and HIE?  According to most experts, accepting these standards takes the willingness of the participants involved.  For business reasons, many large organizations do not support standardization, and so interoperability--a functionality fully dependent on standardization-- is not an easy task.  Even if a hospital may be willing to accept the interoperability challenge, the cost of implementation is often artificially elevated by the proprietary vendors, making it prohibitive.

A related factor, referred to above with the term "hybrid", is the fantasy of a one size fits all product.  Hospital IT departments love hybrids because they theoretically means less hassle.  Their focus is less on the end-user than on avoiding potential problems for the IT department.

Hospitals, CEOs, private practitioners, politicians, and all health-care advocates should encourage their EHR vendors to allow the concept of interoperability to be enacted upon and enhanced.  You can find more information on the subject at the Center for Medical Interoperability.

Scientific Basis of "OM"

The power of meditation is explained quite well in the article, From OM to OMG: Science, Your Brain, and the Productive Powers of Meditation.  It analyzed the brain by MRI scan that is meditating to the normal active brain.  She claims it leads to better focus, less anxiety, more compassion, more creativity, better memory, less stress, and more grey matter.  The aging population especially myself can use all of these.

Meditation turns off the tumultuous, endless thoughts produced by the brain allowing one to focus with mindfulness on nothing or a particular pathway.  OM or any mantra is a sacred utterance, numinous sound, or a syllable, word, phonemes, or group of words believed by some to have psychological an spiritual power is a vehicle to achieve a meditative state.  OM is the vibration of the universe- more than a sound, but the vibration.  What's the bottom line for most people who are skeptics?  The benefits outweigh the negatives of trying it.  What if it really works?  Take advantage of easy solutions to complex problems.

This is all well and good for those who wish to spend time in a cross-legged position, or chanting, or meditating on koans, but one would eventually be led to ask, "What is brain anyway?".  What is mind?  As the Zen adept will note: if you understand, well then, things are as they are.  And if you do not understand guess what?  Things still are as they are.  Quite likely the brain exists in the physical universe very much like a smart phone on a plan; the data probably exists in multiple dimensions, and as the phone works and the brain has not stroked out, the information is there.  But does it matter that we get it?  Indeed when asked to walk the dog one should first reflect on the hope that someone's karma does not run over your dogma.