However, my particular EMR system has gone out of service twice in the past two months, much to my disappointment. Both times were for, it seems, less than an hour, but extremely painful to live through.  Moreover, since there have been multiple service outages over the past few years, I have gotten more accustomed to the emergency changes that our office needs to take immediately the moment we discover an outage and patients continue to roll in for their visits.

However, it still makes me wonder what ethics might be involved here. On the one hand, occasionally every service might be expected to have outages. Power, water, mail, etc.  Few if any of these services need to run in real time continuously for the protection of people’s lives. However, medical records systems really should run or be available continuously because of the need to make, in real time, medical judgements and plans that affect peoples’ lives.  There is a real problem when medical records are suddenly inaccessible during meetings between healthcare providers and patients.  Obviously, there are differences in the liabilities depending on setting of patients in hospitals and those in outpatient office practices.

I am not a computer programmer and don’t know the possibilities for obtaining backup records immediately (or if this is even possible) when an EMR service fails.  One would think that a backup server/service could be activated, but in our periodic transient cases we have found that this has never happened.  Nothing really “kicks in”.  We simply wait for service to be restored and in the meantime start searching for lab results through our online access to major commercial lab suppliers (i.e. LabCorp, Quest).

Unfortunately, I do not know the solution to this problem, although it seems to be an issue of product development.  In the past it has occurred when new versions of the software were upgraded, but this has not been the case in every instance that we have experienced.  Currently, there are no regulatory agencies that seem to have jurisdiction to police  real-time backup safety requirements for an EMR system, which leaves a big hole regarding liability and responsibility.

I have to wonder how often this occurs for other EMR systems?

Patient engagement continues to be one of the most common complaints about EMR software.  There was even a mention of the frustrations in a previous post on Happy EMR Doctor.  Many physicians say that it interferes with patient interactions and that now most of their time is spent looking at a computer monitor and updating charts.  This causes frustration for all parties – patients and physicians – because doctors did not sign up for computer duty when they went to medical school and patients expect a doctor’s full attention during visits.

Software Advice, a website that reviews medical software, launched a survey on how to improve doctor-patient interactions in the EMR era and the results are finally in.  See below for the top seven tips received on maintaining quality relationships:

1. Position your computer between you and the patient:  No brainer here.  Face the patient during interactions.  Take the time to plan where your equipment will go so that this possible.

2. Invest in mobility:  Whether it’s a small rolling desk, small tablets or other lightweight tools, choose equipment that helps you move around.  A laptop may cost an extra buck but can be worth the investment.

3. Delegate as much as possible:  The objective is to interact with the patient as much as possible.  Have staff members enter the medical history, medications, prior procedures, etc. prior to the patient’s visit so you don’t have to during the appointment.

4. Dictate as much as possible:  Talk with the patient while scribes enter the information or use dictation software.  These allow you to focus more on the patient.

5. Ignore the computer when you first enter the room:  Chat with your patient for a few minute before you start recording information in the digital record.

6. Ask about previous complaints:  If the patient information is pre-loaded, look over it before entering the room. If they have open complaints, ask them about the issues to close them out in the emr. This reaffirms to the patient that you care.

7. Finish the chart in the room:  This can help to answer any other questions that might come up so patients feel like they have been listened to.

All in all, EMRs take some getting used to.  Once a physician develops a rhythm with the software, every patient interaction becomes easier.  Focus on the tasks as they come, and remember, practice makes perfect.

Denise Amrich wrote on ZDNet Health in July about the Kaiser Permanente method for EHR etiquette.  Called LEVEL, the method advocates:

-Letting the patient look on;
-Eye contact;
-Valuing the computer;
-Explaining what you’re doing; and
-Logging off.

Undoubtedly, some physicians have developed their own best practices for EHR etiquette.  Software Advice is currently hosting a survey to analyze how EMR systems have impacted physician/patient interactions, and what physicians have done to effectively use the technology in their practices.  The survey is only a few questions, and should take only a couple of minutes to complete.

The Software Advice blog is hosting the Patient Interactions with EMR/EHR Use survey.  Data will be collected over the next few months, and a final report and analysis will be shared on the Software Advice blog after the survey has closed.

Since there are no official published guidelines in this area, it seems yet another of many many MANY (did I mention many?) gray zones in the world of digital and mobile health technology.

Like it or not folks, the cut-and-paste function available on any computer is here to stay. It’s up to physicians and other providers like nurse practitioners and physician assistants to choose to use this technology responsibly. Furthermore, I believe that it is not impossible to do so. That would only be logical. Otherwise, we could never acquire anything that made our lives as providers a little easier.

I understand that the Medicare system is practically bankrupt as it is and seeks to minimize fraudulent payouts. I also recognize that there are nefarious individuals out there posing as medical providers who can crank out EMR notes that are identical in a mass-production fashion in order to financially rob the system again and again.

However, let’s not take an anti-EMR philosophy.  Let’s not throw the baby out with the bathwater.  I don’t have the perfect solution, but rather then forbidding medical providers to use the technology in a powerful way to see more patients with less busywork at the end of the day that does not benefit patients whatsoever, I think we need to put more thought into solving this problem. What do they expect doctors to do with EMRs anyway?  Write everything from scratch every time?  Such an approach would be both nonsensical and naive.  And the solution should not be to withdraw the technology or force doctors to do things that are unconventional.

On the contrary, we need guidelines that make sense and do not add needless work to already harried medical professionals.  We need simplicity and not complexity.  We should not seek to recreate the debacle that some people came up with long ago that is the tax code-like nightmare of Evaluation & Management (E&M) guidelines, which are still quite gray in many areas.  We need to be able to empower doctors, NP’s and PAs even further with technology rather than retract abilities that the technology enables.

I’m purposefully not getting into specific examples in this post for the sake of brevity.  But I’ll be happy to take any questions my readers may have.  Who knows, it could lead to interesting future discussions.  For example, the precise definition of “cloning notes”, what qualifies?

A group of researchers led by Dr. Jeffrey Linder at Harvard University’s Brigham and Women’s Hospital studied primary care physicians taking care of 7000 patients with coronary artery disease and diabetes over nine months. The study authors assessed 15 quality measures, three of which were found to be performed significantly less by physicians using a typical dictation system for record-keeping as opposed to those keeping records by electronic medical records systems.  Two of the three standards of care measures that dictating physicians were less likely to provide were tobacco use documentation and diabetic eye examinations.
This parallels my own findings as an endocrinologist using electronic medical records. During the period of my early years before I instituted widespread use of templating, I was much less likely to hit all of the quality care measure marks compared with after instituting templates.  It’s actually quite commonsensical that a medical provider can hit all of the marks if they are prompted by the computer.  In a sense, the care goes on autopilot.  No matter how chaotic a given point in the day of a busy doctor might be, it becomes impossible to complete a note without performing all of the prompts unless doing so deliberately.

There has been at least one or two studies that I’m aware of that have doubted or not found the conclusion that electronic medical records improve the quality of care patients receive.  I think that most likely these studies did not find a significant association because they were not properly designed.  When one considers the volume of quality measures pertinent to a typical patient visit with diabetes or coronary artery disease, there are so many measures that unless every physician has the measures memorized and never forgets anything, gets flustered or has to hurry through the visit, there will almost be a guarantee that not all measures will be addressed at a visit.  I’ll take that bet and win every time.

The fact that there are now at least two studies showing a positive relationship between the quality of care given to diabetic patients in the use of electronic medical records documentation is even stronger evidence that this is a real phenomenon.  Personally, I can’t believe that anybody would think that electronic medical records don’t lead to better care, regardless of the degree of such improvement.  That is, unless they’re not using the templating advantage.

Rob Lamberts, MD, wrote an interesting post titled Ten Ways to Make the EMR Meaningful and Useful. I have to admit, his suggestions made an awful lot of sense. They started me thinking about how useless much of my own documentation is because of its origination in archaic rules for receiving insurance reimbursement money. Unfortunately, it seems that a lot of these rules stem from the medical profession itself rather than have been having been thought of exclusively by insurance moguls. For example, the family history is usually almost entirely irrelevant to what my scope of practice generally entails. The Review of Systems (ROS), which is the part of the exam where we as doctors ask the patient a myriad of questions regarding their symptoms, is typically exhaustive, unproductive and usually despised by most practicing physicians. Patients are generally very forthcoming about any active symptoms that they are currently experiencing, and a few additional questions around their symptoms typically suffices for a doctor’s purposes.

The majority of old medical records that I get from previous practices in which the patient has been involved are usually either illegible, irrelevant, or not directly related to the reason the patient is coming in to see me. If I am seeing them for the same purpose and they are just transferring their care to me, I generally will ask much of the same questions that have been asked before, rendering the review of records of even more limited value.

I think that getting meaningful use out of our own individual records could be greatly helped by an overhaul of the medical profession’s recommendations to insurance companies on the types of information that needs to be included in medical office notes for the purposes of providing excellent healthcare. In the increasingly complex and technologically-advanced society in which we live, information “noise” really should be kept at a minimum, especially in providing appropriate healthcare recommendations to patients. Medical records should not be in a habit of containing information that does not change or impact the medical management of the patient. We really need to revisit the idea of “gee whiz” type of data and cut out any extraneous documentation.

This would, of course, require that meaningful use become much more personalized and individualized to specific doctors and their specialties. The current state of meaningful use is actually fairly limited in that it applies mostly to primary care providers making recommendations for preventive health care. Preventive health care, unfortunately, is almost never the reason why patients seek the advanced medical knowledge of specialists and subspecialists in specific areas of medicine.

In summary, I agree with Dr. Lamberts that we need to overhaul meaningful use into something that is much more meaningful and usable.

But who are these patients, really?

Are they the well and well-to-do, middle to upper-class population who are internet-savvy, highly educated, and compliant with following the plans suggested by the healthcare provider?

Are they the patient struggling with chronic illnesses, the symptoms of which may tend to wax and wane on a daily basis, making their issues a daily struggle?

Are they the poverty-stricken residents of typically lower class neighborhoods in metropolitan areas, who may have more limited access to digital technology?

From my personal experience in a downtown metropolitan area, namely Washington, DC, I can tell you that most of the patients who are engaged in seeking out new information regarding their health conditions tend to be highly educated, middle to upper-class patients with excellent access to digital technology.

But I have to come back to the initial comment in question, which begs the question of who should we really be targeting?  Who can really take the most advantage to gain from the digital healthcare revolution?

I could take the Pollyanna-esque view that everyone should be able to take advantage of everything equally and we should all just get along and be happy.  However, real-world experience tells me that there may be a different answer this question.  There are also limited resources for healthcare outreach campaigns.  Therefore, it would seem appropriate to do more research into the area to really define who the best targets are for the maximum benefits. It certainly seems like a valuable question to answer and one that’s worth going after.  What do you think?

No longer are the former etiquette protocols sufficient for interacting in the digital era. Now, patient engagement includes Internet searches using “Dr. Google” for what in my opinion are typically anxiety-fueled questions that are frequently unnecessary and irrelevant and would not have been asked prior to the arrival of Internet searches.

However, the internet isn’t going anywhere anytime soon, and so providers have to be able to deal with this new level of interaction. Fortunately, not all patient engagement is so maladaptive.

Patient engagement is a funny thing though. It seems to be confused by doctors, staff and patients. Some people think patient engagement involves E-medicine, or rather electronic visits over secure messaging systems. I laughed the other day when I viewed a YouTube video showing a woman talking about a third party for-profit software vendor company using their technology to allow patients to pay bills online and therefore be more” engaged”. Right. That’s twistier than Presidential campaign rhetoric.

Another speaker put it well when he said that “reality struggles to keep up with the rhetoric” when he was commenting on the difficulty in defining patient engagement, yet everyone wants to use the jargon liberally.

I prefer to think of patient engagement in the digital era as being positive in several respects. I expect the patients to take an active role in their healthcare, in gaining knowledge about their disease, and in gaining knowledge about health prevention and treating ongoing illness issues. In doing so, the patient becomes empowered to take an active role in the decision-making process during the testing and treatment phases of care. This is not to say the patient should get to consult Dr. Google and then dictate what tests are being done on them regardless of what the ordering provider thinks is appropriate. I think the most ethical and appropriate response to such requests are to, first, consider them seriously; second, discuss with the patient which tests are medically indicated and which tests are medically unnecessary; and finally, to stand one’s ground in either writing or not writing for any medically unnecessary tests to be ordered.

I also completely agree with the definition of patient engagement as defined by the Society for Participatory Medicine. It says that patient engagement is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.

In order to get patients more engaged in participating in their healthcare, I think we need to make it fun, make it interesting, and communicate using means where the patient actually is, on multiple levels of “is”. In the case of the digitally connected patient, we should be considering communicating using the Internet, smartphones, and mobile devices such as iPads. We need to be able to make this communication valuable to the patient so that they, in turn, want more of it, and so that the movement grows.

One of the biggest holes in electronic medical records currently seems to be a lack of secure messaging systems built into the software.  Although maybe not universally true, this still represents a huge problem that also represents a great opportunity for gains in technology that will enhance the doctor-patient relationship and move digital healthcare forward into the future.

Currently, my electronic medical record vendor does not supply this feature as part of its software package.  However, as part of the Meaningful Use Stage 2 requirements by the federal government, the use of a certified EMR system that supports this function will be required.  A HIPAA-compliant secure messaging system will be needed as a part of every electronic medical record going forward.

Currently, if I wanted to use secure messaging to communicate with my patients, I would have to purchase a separate third-party vendor’s online software to communicate in a HIPAA-compliant fashion.  This involves an additional service agreement between the third-party and me, as well as monthly fees they can be expensive.  This would grant me the right to not only communicate with patients but also to bill third-party insurance companies for providing such electronic health services.  However, what may people do not appreciate is the small reimbursement allowance for such services, which is quite minimal.  Thus, regardless of the demand by patients, it’s currently more financially lucrative simply to see another patient in the office for a follow-up visit rather than answer a message electronically.  If an electronic medical record vendor builds secure patient messaging into their platform, when there is already a contractual arrangement between the doctor and EMR vendor, then a third-party cost would potentially become unnecessary.  The prospect of using a built-in, HIPAA-compliant, secure messaging system suddenly becomes much more attractive and potentially fiscally responsible.

Unfortunately, many EMR systems are in still developing stages at which they do not yet have built-in secure messaging features in their PHR or personal health record modules.

But what a wonderful and potentially powerful area for future development in order to further promote patients to become more engaged in playing a more active role in their own health care.  The ability of a patient to reach their doctor through the Internet is certainly an attractive feature if done right and seems potentially better than a patient spending five minutes on hold listening to elevator music only to finally speak to a front desk staff member who will only be able to forward a message, which may or may not be forwarded accurately.

What doctors can do to maximize the potential of technology to improve care,

What workflows and techniques providers can implement to enhance their relationships with patients,

How providers can inspire patients to take an active role in their health management through health IT, and

Which policies and industry innovations can facilitate better patient-provider relationships and value-based care.

An old mentor of mine once gave me wise advice. “Whatever you do, make it count twice.” In other words, if, for example you are preparing a talk, the opportunity may arise later to turn this into a paper/manuscript that you can submit to a journal. Perhaps you can even give a version of the talk as recycled talk at another conference for slightly different purpose. In other words, be efficient!  Turn a dollar into two… or even more.

Therefore, I’d like to share with you some of the ideas that are coming to me as I proceed towards the panel on Tuesday.

What can doctors do to maximize the potential of technology to improve care?  Well, first off, we can simply use it.  Far too many doctors are still using paper records.  My advice would be to get off of paper records and forge ahead into the New World of electronic records, which is quickly becoming not such a new world anymore. This is becoming more and more the standard and will continue to do so in the future. Secondly, I would highly encourage any medical provider out there to use a web-based system as opposed to an older, in-office server-based system. This allows more opportunity to use the technology outside of the office, particularly on mobile devices. Thus, there’s more opportunity for portability and accessibility. I can’t tell you how many times I have been at home or out of town on the weekend or in another country for a few day, and this technology becomes invaluable in allowing me to continue to provide healthcare to my many patients. This can come in the form of prescription refills and communications to patients by messaging my staff to give them a call back. If my patient portal allowed it, which it currently does not, I could even securely message my patients regarding any issues they may be currently having.

Regarding workflows and techniques providers can implement to enhance relationships with patients, I advise turning the computer monitor during office visits to show patiences test results, especially images, more clearly. This will give them the opportunity to ask questions and see firsthand things that might inspire them to be more interested in asking questions. Hence, the visit becomes more of a two-way interaction rather than simply the doctor preaching from on high the recommendations. At the end of patient visits, I currently offer to enroll them in our personalized health record, PHR, so that they can have access to their test results, upcoming appointment information, and diagnoses. This is a far cry from granting them complete access to all the records, but it is a useful start. Patients absolutely love it and have given me a lot of positive feedback. At future visits, patients are then more likely to request me to turn on access to the latest test results, indicating that they are aware that they have personalized access to their health information.

How can providers inspire patients to take an active role in their health management through health IT? As providers, I think it is imperative that we encourage the mainstream media to develop better marketing strategies. Patients need to value and want this in the first place before it can happen. In the meantime, providers can use electronic medical records with a personal health record component. This will grant patients the opportunity and access to become more interested in their healthcare and get inspired with new ideas for such. We providers should advertise openly to patients that a personal health record is available in our offices. Only through knowledge can power come. Finally, we as providers can discuss opportunities for the use of health IT to manage chronic health issues like high blood pressure and diabetes with patients. Providers admittedly need better knowledge in this area, especially since barriers include the massive volume of health IT apps already out on the market. There’s dizzying display of options which often inspire the providers to just simply turn off the computer and go do something else. I also think we need more public advocates among the provider community, people who truly view this as their mission in life, which most providers arguably do not. They are not trained to have such a mission and they are already very busy with providing good health care to the many patients who need it. Thus, identifying key providers in local communities who have a true passion for developing future use and promotion of health information technology is essential in order to inspire other doctors to jump on the bandwagon.

As far as the “policy and industry innovations that can facilitate better patient-provider relationships and value-based care”, I might have to defer that one to my colleagues who are specially trained in how these things typically develop and mature.  In that vein, I’ll be very interested in what my fellow panelists have to say.  Hope to see you at the conference!