Posted via web from Peter Beck Kim’s Other Blog

It’s not quite the world’s oldest profession.

More like civilization’s.

It predates EHRs, paper, papyrus…even clay.

So long as there has been writing, even on stone tablets, there have been scribes.

Folks trained to commit words to a more durable medium than fallible memory.

Folks who did nothing else besides that special act of translation.

Because the movers and shakers who were actually talking, doing, or thinking the important stuff were busy with the important stuff — and were unable to scribe simultaneously, and too busy to learn.

Sound familiar?

It Sounded Like A Bad Joke, Actually

The idea first came to my attention from one of The EHR/EMR Show’s readers in 2008. At the time, I thought it was a step backwards: another layer between the physician and the medical record, like a court stenographer with one of those cryptic keypads.

Now, I’m not so sure.

No question this is a niche market occupation, like personal shopping. But if a physician is either too busy or just plain unable to learn to use his EHR to document efficiently — yet has no choice but to use it in order to continue medical practice — how outlandish an idea is it, to have a scribe as the human interface to that digital system?

Many ERs currently use medical scribes for their emergency room physicians — not for EHR interfacing, but simply to navigate their walk-in, critical care shifts. The physicians see the patients and call out the key notations to their scribes, never having to take their eyes off the patients, and the scribes dutifully note the history and observations, order what they’re told to order, and collate the results and notes for the final doctor’s review before the patient leaves.

For an EHR-challenged physician, a medical scribe might work similarly. Such a physician may have a hard time learning an EHR’s clicks and checkboxes — or in some cases, even how to type — but every doctor knows how to talk. And the scribe knows where the buttons, checkboxes, and on-screen order forms are. The doctor can look sage and speak freely, and the medical scribe transcribes all that info into the discrete clicks and data fields that healthcare systems love.

Blasphemy, Dr. Langdon

If you’re reading this blog, you’re hopefully among The Illuminati, and beyond needing such assistive services.

Or at least an initiate, soon to join the ranks of those who can finish notes by the time you walk out of the exam room, run reports against your patient data, and otherwise

• see a few more patients than before
• do so more safely than before
• legitimately code higher than you did before
• go home earlier than you did before
• in an office that runs 3 times more efficiently than it did before

But in case it isn’t obvious by now, attaining this state takes a village, and the majority of American physicians haven’t gotten here, yet.

EHRs are evolving fast, and ease of use and customizability — convenience, even — will become major differentiators in a field of similar feature sets. But as of today, they still demand a fair amount of patience, diligence, and networking to successfully implement. Higher brain functions, all.

Front line physicians function more as solitary operators, taking all comers and fighting to survive the day. From the lizard brain, if you will. And the lizard brain is stronger and louder than the superego, as we all know.

In an environment where you hit the ground running from your first day on the wards and never stop, and are incentivized both by training and by reimbursement to provide a critical service as your sole means of purely active income, is it any wonder that it’s an uphill battle to teach doctors a fundamentally different way of doing things?

Can Doctors Learn To Do It?

Of course…but “doctors” aren’t a homogeneous monolithic group, any more than “overweight patients” are. And in the same way, some will get the message immediately and turn their lives around. Some will maintain their set points with some degree of struggle. And some will get steadily worse.

Psychology 101 (and Marketing 301) spell it out: it’s easier to play to someone’s point of view than to turn it around. If the success of your venture depends on Making A New Man out of your prospects, you’d better be prepared to for a siege: tech support, help desks, educational materials, physician advisors…or a really big stick.

Changing a worldview isn’t impossible, it just takes work.

What If You’re Not One Of The Elect?

The whole premise of this blog — and indeed, the business models of most EHR vendors out there — is that you can turn your attitude around once you see the light, via the carrot or the stick. Enlightenment is grand, but Survival is a marvelous motivator, so to speak. I’ve seen it work time and time again: you accept the reality, do what it takes, and move on.

What about those struggling colleagues who can’t make the switch, no matter what the incentive, rationale, or threat?

Imagine that 3 years from now, the prevalent medical business model still demands that doctors see more patients, in less time, just to break even. And that tort reform is still a happy hour joke, and EHRs still aren’t as easy to use as Google’s Gmail. How can your challenged colleagues, doing the best that they can, bridge the too wide gap between their mounds of medical work and how to translate that into their EHRs?

Enter the medical scribe.

Caveats

This wouldn’t even be a discussion worth having, were it not for a basic concept called evolution.

Doctors evolve, EHR systems evolve, and the healthcare system is evolving. And each, while intertwined with the others, is evolving at a different rate.

Most of the focus on adapting has been on physicians and their offices: small groups of humans can change faster than organizations (EHR vendors) and the entire U.S. healthcare system.

That balance sheet is changing, with the incredible selection pressures being brought to bear with healthcare as the primary focus of the nation’s economy. But substantive change in the next few years will still be up to physicians — and as the still low EHR adoption numbers show, some doctors and local healthcare systems just can’t adapt.

Scribes cost. As Gugliemo points out in his Medical Economics article, it requires time — about 2 years of commitment from the scribe — as well as training in the EHR and the physician office workflow. You have to pay the scribe, too, although the balance sheets can look good (a modest cost, for moderately increased efficiency, patients per day, and doctor satisfaction).

We don’t use scribes any more for everyday information processing, because as a society we’ve evolved to make them superfluous. But EHRs are still early in their evolutionary cycle, while the pressures to use them are high and immediate.

It took 8,000 years to go from royal scribes to everyday reading and writing without them — requiring a groundbreaking invention called the printing press and a little social reform called, oddly enough, The Reformation. Things move a lot quicker in the digital age, but if the gap is just too wide for you, medical scribes might be a useful alternative to an epic fail.

You’re halfway home. Part 1 discussed Tests 1-4, for picking physician-friendly EHR features — and avoiding those that would incite a riot.

5. Pare With Care

Eventually, you’ll feel tempted to carve away what seem like excesses — don’t do it! Not without checking at least three times!

Scut step reduction always gets a PASS, if by “scut” you mean “multiple steps that are invariably done in a sequence that can’t go otherwise.”

So if you ALWAYS sign-off a lab value by

1. removing it from your lab listing
2. tasking a staffer to notify the patient
3. instructing the staffer on what new action the patient must take

then it makes sense to carve away 2 of those steps, and to have a single button that does all 3.

If at any point, however, something else might happen — like you’d want to keep a lab value in your listing once in a while, or an office colleague might notify the patient instead of the staffer — then prepare for howls of protest if you take away those other options.

Sometimes those other options might not make sense. The need for them may occur incredibly rarely. But, if you don’t thoroughly investigate these branching pathways before you cut them, I can guarantee that you’ll take out weight-bearing walls for certain practices.

6. Always Customize By Provider, If You Have The Option

This does NOT mean to build a secret garden for each and every doctor; it means, given the option to provide adjustable settings at the enterprise vs. practice vs. provider level, it’s hard to go wrong with the lowest level.

If the system will allow it, let each doctor make and save their own customized lists, plans, macros, etc. Physician variance is legendary; consensus, like the kindness of strangers, is less of a sure bet.

7. If Something Works, Copy It Shamelessly

Life is short, and medical office workflows are complicated.

If there’s a doctor-approved example of something that works and is popular, why ignore that and start from scratch (especially from scratch without clinician input)?

When you hear comments like, “Oh, I always use the XYZ system” from every specialist you talk to, or “When the fur is flying and there’s nobody to help me, especially the comatose patient, I can always rely on ABC to get me out of a tight spot,” those are the X-marks on the tattered map that tell you “Here Be Treasure.”

Physicians can come up with some pretty imaginative and roundabout ways of doing things, but they instantly know a good thing when they see it. A good engineer knows the value of starting from a solid, working model whenever possible. The key is to acknowledge that “solid,” and “working” are concepts best vetted by physicians, when it comes to healthcare IT.

Are there any litmus tests that you’ve found valuable for separating the gold from the lead? Please put it in the Comments section below!

Imagine participating in an EHR advisory group for your area.

Every month or so, you meet to hammer out and vett new directions that your medical record will take. Which mods to bring in, when to do major and minor upgrades, how to educate physicians and staff about the transitions, and so on.

And every month, you’re surprised with what folks rate a PASS or a FAIL. Every single time.

I’ve been in these fun little shoes. It’s embarrassing if you’re the “physician champion,” and one of your duties is to minimize organizational surprises from doctor pushback. Being surprised keeps life interesting, but entertainment value is limited when it means going back to the drawing board.

Sooo…I’ve distilled a list of 7 Key Tests — filters — to grade new features before they get too far down the development pathway. Looking back on our Group’s meetings minutes, I think they work pretty well.

Part 1 deals with the first four tests.

1. Any Information To Be Filed Must Have Doctor Approval Or Awareness

This is a biggie for medicolegal reasons. As an IT advisor or the practicing physician, you want to be real careful about bringing anything into the chart without some kind of signoff process — the data must pass doctor eyeballs before it gets filed away in the digital bowels of the chart. The physician is ultimately on the hook for info in the chart, and docs hate it when they’re tagged for abnormal results that apparently they never saw, and thus couldn’t have acted upon.

Protocols for colleagues and assistants fall under this. A mid level or colleague may be empowered to refill certain meds without consulting with the original doctor, for instance — but only because the protocol to do so has already been worked out in advance. The doctor has already “laid eyes” on this workflow, and approved it.

Nothing gets filed without a doctor being flagged on it. It doesn’t have to be a big hairy approval deal, but physicians need a chance to maybe do something, if warranted.

2. External Resources To Take Care Of Scut In A Cheap, Dedicated Fashion = PASS

As noted in a previous post, doctors are super busy. Taking care of “scut” — in this case, repetitive tasks that could be handled just as well by someone below the physician’s level of licensure — frees up mountains of resources. And there’s always plenty of scut.

The doctor could grind through it. The office staff could grind through it for less than the doctor being tied up. And if possible, and external agency, like a practice management group, IPA, or even a private company, could grind through it in an expert, hyper efficient fashion for even less.

Examples of this include signing patients up for secure portal (email-like) communications, and gathering results and consultant notes prior to the next follow-up appointment.

The business proposition is to maximize the doctor’s time. Doctors work best, bringing their observational and decision making skills to bear, not running around calling for test results, or waiting around for callbacks.

3. Get Doctor Signoff Before Proceeding With System Changes — Repeatedly

You’d think it’d be enough to show ask someone once if they like a new feature. But it ain’t necessarily so.

Doctors evolve, like anyone else. Especially if any proposed modifications will take time to develop and implement, they are going to continue to change and mature during the development process. When the IT group turns around with the final product, the doctors may have advanced out from under it, and say, “Who the heck came up with that bright idea?”

Doctors need to be shown, repeatedly and explicitly — not just conceptually — how major mods are taking shape.

4. 1-Click Is Best, 2-Clicks Is Status Quo, Anything Else…Not So Good

This is a tough one; it lies almost entirely in the realm of the vendor, or an external group creating modifications.

But doctors are busy folk. They do repetitive tasks with almost every patient.

Whether looking up info or taking action, key repetitive tasks should be 1, maybe 2 levels tops, away from where they are on-screen.

Physicians will eventually complain if these take more than 2 steps — and will immediately be grateful if a 9-step process gets pared to 4. Or 1.

At the latest NextGen Users Group Meeting in DC, I saw examples everywhere of storytelling par excellence.

Former Speaker Newt Gingrich and Vermont Governor Howard Dean sprinkled stories of constituents and personal experiences throughout their keynote addresses, as they made their respective (and mostly complementary) points on the healthcare reform debate.

The first day’s keynote speakers, Gene Kranz of Mission Control and Commander Jim Lowell from Apollo 13, were all about storytelling. 99% of their stage time was a recounting of details of raw ingenuity and failure truly not being an option — and 45 minutes into the session, folks were still attentive enough to laugh and groan in all the right places.

It’s like we’re hardwired to put everything aside and sit back on our haunches, rubbing our hands together in anticipation, when the village storyteller steps forward and clears his throat.

When the rest of the tribe is watching, what story are you telling with your approach to healthcare IT?

Story? I Need A Story?

Actually, you’ve already got one, whether you like it or not.

And if you haven’t devoted any effort into crafting it the way you’d like to be known, your “audience” — your patients, your colleagues, your physicians or IT personnel — has already made one up for you, to tag you in their own minds.

I was a co-presenter at the conference, and this was my primary contribution to the talk. Turning Doctors Into Raving EHR Fans was the topic, and there were action items aplenty. Managing expectations, spiffying up your support crew, soliciting physician input, using surveying and video producing tools to uncover and deliver wanted training — these are necessary and key items that any successful EHR rollout must have.

But in order to be ranked “highly satisfactory,” an organization needs to deliver more. A healthcare IT group needs to convey a key story in every support call it takes, every instructional video it produces, every sit-down chit chat it has with a displeased doctor.

The content of that story is entirely up to you. It can be “You’re The Center Of Our Existence,” “We Value You,” or “We’re Giving You Our Best, Take It Or Leave It.”

The important thing is that whatever that story is, you consistently and believably convey it.

But I Do Already

I would respectfully submit that if you’re an organization and not devoting quantifiable time and budgeted dollars to marketing — or if you’re a physician and not studying and discussing how your patients and colleagues perceive your office — you are totally not involved in crafting and communicating your message. And since thinking in terms of stories is as natural as licking your chops, that implies that other folks are making up your story for you.

You may be doing your best as a phone staffer doing tech support. But if you’re swamped with the call volume, and 8% of your callers hang up before you get to them, what kind of story are they hanging up with?

You may be coding your heart out as a local IT programmer, doing mods up the wazoo of the vendor’s EHR. But if you repeatedly tell your docs, “Sorry, can’t do that, that’s the vendor’s fault,” what message are they walking away with (hint: rhymes with “PAIL,”, starts with “F”).

You may be keeping long lists of EHR complaints as a busy doctor, and yelling regularly at your local phone support. But if you never take the time to attend training sessions, or to learn the difference between what’s possible and what’s improbable given the limitations of your support team, what story are you screaming at them?

Can you really afford to have other folks define your story for you?

There Are Exceptions, But Precious Few

Actions do speak louder than words if you’re not careful. But if you tell your story right, your message can mitigate your goofs.

Case in point: iPhones and Starbucks.

Nearly everyone with a smartphone at the UGM had a Blackberry; I counted something like a 5:1 ratio of Blackberries to iPhones. But try impressing an iPhone user (like myself) with those stats. iPhones = Apple Computing = innovative + fun + company that appreciates my cool, quirky, and poetic approach to life.

But doesn’t Apple’s iPhoto app have some glitches, like the crossfade between slideshow songs not working in the most annoying way? Doesn’t the iPhone’s lack of a tactile keyboard mean lots of texting errors? Well, yes.

Yes, But…

What about Starbucks? I chat with a barrista several times a week, and their coffee and snacks are fine.

But is their $5 grande espresso whatever truly 5 times better than the $1 coffee you get at Cuppa Joe’s? Well, no.

No, But…

But I’m not buying just a smartphone or a cup of coffee. I’m buying entry into an experience — an experience so supportive of my worldview that I’m willing to overlook certain deficiencies. Like the teacher’s pet: once they were the darlings (great students, and they so totally get what I’m trying to teach), they pretty much stayed the darlings, even if they came to class late once in a while.

And you had better believe that those customer experiences were crafted with great, corporate levels of care. Those experiences — those stories — are what are really being sold.

You can’t feel highly satisfied with a basic product or service. Only a story — a message, a concept, an ideal — can do that.

So What’s This Got To Do With Me?

Remember that little healthcare reform topic that formed the core of keynote address #2? With Gingrich and Dean as the co-speakers?

Both politicians used storytelling to generate more thought and buzz for their missions. Without even trying hard, they created partisan applause and murmured mmm-hmms at appropriate places throughout their talks. Agreement and zeal. Doctors, IT folk, and office managers are no less vulnerable to the Gather ‘Round The Fire reflex than anybody else.

Telling a story is one of the main tools of effective copywriting, but as Seth Godin points out, it’s absolutely central to generating energy and enthusiasm for your mission.

Take advantage of that reflex. Get folks to pay attention. And as they sashay forward along the story’s glide path, guide them into the berth that you’ve prepared for them, or womp them with the eye-opener that shakes them out of their complacency.