Physicians Preservation Act?

I got this idea today while reading the usual Twitter complaints about the electronic health record. A post by physician I knew was particularly poignant. She pointed out that she was getting burnout from the excessive time it takes to do EHR documentation compounded by the fact that nobody ever reads it. This is a complaint I have had for a long time.  I was lucky enough to be on the ground as the EHRs rolled out. There was quite a prelude to the rollout with about a solid 10-year buildup of documentation and billing requirements. Those requirements originated with the federal government specifically HCFA – the precursor to CMS. All of the initial EHRs were designed around these documentation and coding templates. It was strictly a business focus sold as something necessary for medical practice.

I can recall the first people on the medical staff who were designated to sell the system. They came to see me and I pointed out that I have never been a touch typist and the fastest I can type is 12 words a minute with two mistakes. When they realized I wasn’t kidding they tried to soften the blow by saying that we would be slowly transitioned to creating the entire document. During that transition time we would still be able to dictate admission notes and discharge summaries. When I complained that this would still be quite a burden on physicians producing all these documents I was told by an internist (who I had a very high opinion of) “You need to thank our CEO for getting us this state-of-the-art system.” That was one of the more depressing remarks that I’ve heard in my career.

I did try to make the most of it. I got an early version of Dragon and started dictating all my notes and into Word and pasting them into the EHR.  It was not pretty. There were many mistakes and if I missed some of those mistakes it could prove to be an embarrassing document. The nursing staff I worked with helped to edit those documents and point out the mistakes but some mistakes invariably went through. I learned that the nursing staff in my immediate proximity were the only people who ever read those notes. I was generating multiple 500 to 1000 word documents a day and suddenly realized that I had to complete that work between 10 PM and midnight every day. Within a few years the new car smell was off the EHR and things were getting ugly.  I started to see 18 to 20 page progress notes based on import and cut-and-paste features. My speculation is at one point the vendor was desperate to prove they could introduce some physician friendly features. The ability to start a new daily progress note based on yesterday’s note soon became history. Administrators decided that the new note looked too much like the old note even though they were based on same template.

EHR politics is always interesting to observe. There are a cadre of administrators and “super users” who are tasked with selling the product to the frontline physicians. There are also various helpdesks that are run by the vendor. Staff at those helpdesks are supposed to be available for troubleshooting and problem solving. The troubleshooting and problem solving eventually fades away. EHRs are typically implemented in modules. I walked into work one morning and realized that the module that allowed electronic prescribing was completely changed. The change was not announced and since it was an enterprise wide implementation there were hundreds of physicians trying to figure it out for themselves. It added hours to everyone’s day.

With the shift of billing, coding, and documentation to physicians many other jobs were lost due to the EHR. For 15 years I would go to the basement of the hospital every Sunday and make sure all of my records were dictated and signed. I ran into the same staff there every weekend who greeted me and assisted me with completing those records. Suddenly they were gone because now I was doing all of their work in the EHR. When I first started working at my job, I would dictate daily progress notes and they would be pasted into the chart by the secretarial staff the next day. Billing and coding specialists would come to the unit, read those notes, and attach a billing fee. I had no idea about the billing system and didn’t really care. With the EHR all of those staff were replaced. I was not only doing their jobs but now I was legally responsible for any billing errors and the suggested penalties were high. All of this additional work and responsibility was directly transferred to physicians through the EHR.

The only real bright spot from the EHR was the ability to see imaging studies, electrocardiograms, and laboratory results as soon as they were available. It took years to get that implemented to the point it worked effectively.

Are there workarounds to successfully use the EHR without burnout, depression, and excessive work? I think that there are. The last few years I have been seen by ophthalmologists who were retinal specialists and an otolaryngologist or ENT physician. In both cases these positions were using a scribe or a third person in the room who documented the history, exam, findings, and treatment plan as indicated by the physician. In the case of the retinal specialist he was working with an ophthalmology fellow and made corrections to that examination by directions to the scribe. The same thing happened with the ENT physician but in that case the scribe was also an RN who could provide more details about the suggested treatment plan. In both cases the physician walked out of the room at the end of the encounter with no further documentation burden. That led one of my colleagues to point out that the only reasonable workaround for the EHR problem is to use two people - the physician and a scribe or staff person who could also function as a scribe.

That led to my idea about the Physicians Preservation Act at the top of this post. It addresses all the flaws in the system that were brought about by heavy lobbying and Congressional advocacy for a burdensome inefficient electronic documentation system. As I pointed out in a 2015 post, the system has never lived up to claims of efficiency or savings even when physicians started to do the work of four or five people. This entire administrative structure is there to produce excessive documentation that nobody reads. There is also a massive environmental cost since the system must operate through thousands of networked personal computers that in many cases are operating 24/7 along with the associated data storage facilities. 

My suggested solution is a compromise between the likely inertia of the current EHR system and the politics that keep it in place and the massive burden it places on physicians and their families. There are just too many special interests in Congress keeping this system afloat. The question is how long can the country afford to lose doctors because of it.

My guess is not too much longer.

George Dawson, MD, DFAPA

Dreaming of the EHR

The Dream:

I am at the APA convention.

It is in a crummy hotel attached to a mall. I am going down to the street level in an elevator and it stops at a level where there is a big cinema complex. An 8 year old boy runs excitedly into the elevator and jams in to my left. The elevator is crowded. He looks at my name badge and says: "What would George Dawson say if the Watson computer said he wasn't doing a good job?"

I glance down at him and say: "George Dawson would not care."

The kid says: "That's not good" and laughs intensely.......


It is all a dream. I had that dream early Saturday morning. It doesn't require detailed analysis. That last thing I did on Friday was try to review a 22-page paper record that was generated by a modern electronic health record (EHR) system. With the exception of a few paragraphs it was largely unintelligible. It contained bits and pieces of information. I was looking for imaging (CT, MRI, ultrasound reports) and ECG data, but instead could find only a few lines that summarized fewer results. There were no dates - no hospital admission or discharge date.  Although the hospitalization was longer than a week - there was no medication administration record or MAR - showing the specific dates when medications were changed.  There were no comprehensive reports that I am used to seeing for the past 30 years from Radiologists. There was no discharge summary. The documentation was basically unacceptable as a source of clinical information and yet it was created by a very high end, enterprise wide EHR system. It brought back a memory of a mandatory meeting I had with a "coding specialist" about 10 years ago. That person let me know that I had "passed" the documentation review in that I had ticked off the necessary "bullet points" so that documentation specialists would approve my EHR note for the day and the associated billing document that had to be submitted with each note.  She showed me how I could do things faster by ticking off a series of check boxes and electronically signing the note.  She was shocked when I told her that I really could not sign my name to that document because there was no sign that an intelligent human being had seen the patient.  For all of these reasons, very poor documentation in the EHR is always on my mind.

My attempt to read the last report may have been enough of a reason for the dream, but I also spent time on Thursday with a colleague who really dislikes the EHR for additional reasons. We regaled our spouses with tales of incomprehensible reports.  In addition, his reports require a synthesis of many imaging, lab, and clinical reports.  He previously used a system where all of the reports showed up in a queue and he could go down that list in chronological order to dictate the report.  In the new system, he has to go to tabs to find all of the reports he is looking for.  Some of these tabs are hyperlinked and the reports don't load very well.  In the end, he and his colleagues end up printing out all of the reports on paper so they can dictate then more efficiently without having to search for what they need in real time in the EHR.  That reminded me of an experiment I did about 8 years ago with the same EHR.  I went in and read all of the clinical notes looking for chronic diagnoses that were not addressed.  I came up with an additional 8 diagnoses from 340 clinical notes buried in the EHR. There is generally no good way for physicians to mine data on their own patients to make sure that they have done the most thorough assessment of their problems.  On the other hand administrators can get detailed numbers of mouse clicks by nurses in primary care clinics and rate their productivity in terms of mouse clicks, screen views, or tasks completed.  My colleague's theory was that the current EHR is selected for the administrative capabilities like monitoring doctors or nurses rather than any inherent advantage for medical staff.  The major evidence for that is that many EHR vendors have permanent staff in the hospital and they are making constant modifications to the EHR.  In many cases there are meetings of all the physicians in a particular department about these modifications.  The hospitals and clinics purchasing these systems are purchasing incomplete products that require what seems like constant revisions.

It has been about 15 years since the blight of the EHR hit physicians.  It was originally called the electronic medical record (EMR) but I suppose some business type decided that they could really solidify the corporate stranglehold on medicine by eliminating the word "medical" from another phrase.  Corporate psychology also dictates that they give the impression that they are maintaining health rather than treating medical problems.  That is another good reason for eliminating the word medical from the corporate lexicon.

The marketing of the EHR has been masterful.  The political hype promised untold savings.  National candidates seemed to suggest that we could actually "save" enough with the EHR that it would cover a substantial part of American health care inflation.  Any physician involved in the implementation phase of enterprise EHRs knew that was a bold faced lie.  There is no way that annual multimillion dollar a year licensing fees as far as the eye can see are going to save anybody any money.  In fact, I am certain that many clinics and hospitals have had to cut staff and services just to bankroll the EHR. Nobody has ever followed the money on the EHR debacle as far as I know.  Congress is well known to invent businesses and turn people into billionaires overnight.  All it takes is a few Congressional mandates about the need to use an EHR and electronic prescribing.  There is no mandate to keep things cost effective of make sure that independent practitioners can afford it.  There are mandates to implement EHRs and electronic prescribing and the White House brags about it.  The following graphic and text are from a White House document on the EHR entitled: More than Half of Doctors Now Use Electronic Health Records Thanks to Administration Policies.

The problem with the White House statement is that despite spending about $3 billion dollars a year and in some cases $44,000 per physician,  the value of the EHR for the reasons already stated remains in question.  It is very handy to be able to pull up lab results and x-rays on a computer screen.  It is also very handy to be able to send electronic prescriptions to any pharmacy in the country.  On the other hand, it is reasonable to expect that a multimillion dollar piece of software will write a report that any hundred dollar database software from the 1990s could write.  That same software should be capable of allowing physicians to search their own patient results for quality and report writing purposes.  In the end we are left with very expensive, high maintenance systems, and massive amounts of information that is either buried in storage because it is not easily accessible or because it is worthless and generated primarily for justifying a billing document.

That is one of the many real costs of having a health care system run by bureaucrats and politicians.  


George Dawson, MD, DFAPA


Attribution:

Photo at the top of this blog is by Paco Burrola on Flickr and is used courtesy of this Creative Commons license.

Let's get rid of worthless documentation

I just became aware of this article by Lucy Hornstein, MD on modifying the current documentation process and found it to be quite exciting because I have had very similar thoughts for some time:

I may be a fellow dinosaur, but I could not agree more.  The vast majority of documentation especially in the EMR is worthless largely because of the proliferation of stereotypical documentation to fit business and government requirements.  The businesses wanted to slow us down at least until they figured out that they could literally reimburse us for whatever they wanted irrespective of the billing code or note.  The politicians want all the bullet points because of the erroneous notion that coders can actually read a note and objectively  decide on the correct code (they can't) and therefore they can fight fraud. 

In the meantime, vast areas of hard drive space are occupied with worthless data because of these notes and the trees die anyway because requesting the information results in an EMR driven telephone book sized tome  with very little information (if any) on each page.

The only thing worse is the EMR driven initiative to rapidly assemble a massive note from existing data using smart text and a few key strokes.  I was on a committee once where we reviewed 10-16 page daily progress notes compiled in various fonts.  The majority of each note was already listed in the record.

I can recall working on a very busy neurosurgical service where we saw 30 patients a day (6-10 in the NICU) and did all the documentation in 2 - 3 hours before going to the OR.  All of the progress notes for the entire hospitalization generally fit on one page.

I have been thinking about Dr. Hornstein's approach for some time and have come to the same conclusion.  The current notes and coding system is basically driven by paranoia and not patient care.  Any EMR system worth its salt should be able to display all of the daily relevant data and provide a check box so there is documentation that the attending reviewed it all and signed off instead of the physician doubling as scribe and displaying it all (after a flurry of mouse clicks) in a massive note.  The actual note needs to reflect the fact that an intelligent life form visited the patient and there is a thoughtful analysis and plan. 


That doesn't happen by filling up templates in an electronic medical record.

George Dawson, MD, DFAPA