The Irony of a Paper TOC Document in an EHR

Over one year ago my office implemented Allscripts Enterprise EHR (Electronic Health Record). I’ve not done a note on paper since. Last week, a “Transition of Care” (TOC) document was placed on my desk with a sticky note stating: “Dr. Nieder please fill out this form so we can bill a 99496 for your visit with Mrs. Jones yesterday”. I pick up two sheets of paper with multiple questions including: 

  • Discharge Medications: (list)
  • Present Medications: (list)
  • Diagnostic tests reviewed/disposition (list)
  • Disease/illness education (discussion documentation)
  • Home health/community services discussion/referrals: (list)
  • Establishment or re-establishment of referral orders for community resources: (list)
  • Discussion with other health care providers: (list)
  • Assessment and support of treatment regimen adherence: (discussion documentation)
  • Appointments coordinated with: (list)
  • Education for self-management, independent living and activities of daily living: (discussion documentation)
Please remember, I am now on an EHR. So I am expected to document in the EHR and THEN fill out these forms. I have no discharge summary yet from the hospital. It may be ready but no one sent it to me and since our hospital is not sync’ed with our ambulatory clinics it didn’t seamlessly flow into my patient’s chart when she was discharged. When I finally do get it, there is no mention of any referrals given other than with the surgeon she saw in the hospital and me. The discharge medications state “resume pre-admission meds”. In order for me to list what tests she had and make sure they are normal I have to return to the hospital portal and look them all up. Some of them have already been scanned into the EHR. I have no idea if there were other referrals made but I doubt it. She had a very straight-forward admission for a small bowel obstruction. She declined to keep the surgeon’s appointment since they gave her instructions in her care in the hospital. I concurred about that. She could call them if she needed them. The women is a healthy 65-year-old who still works part-time as an accountant. She travels a lot. 

This TOC visit is paid at a much higher rate than other visits IF the patient does not return to the hospital in the next 30 days. Hence, we hold the billing until that time. 

My understanding of the purpose of this new code is to improve the CO-ORDINATION of care as the patient transitions from the hospital to home. Coordination would imply that there are other individuals involved in giving the patient care and thus we should have improved COMMUNICATION

between us. However, at least in my institution, my staff and I bear the brunt of gathering information (which is what we normally do anyway, so I guess it’s nice because now we get paid for it). 


At what point will it become incumbent upon the hospital, who I work for, to send me the necessary information for treating the patient now that he/she is home again? How does it follow that improving care means the primary care doctor fills out even MORE FORMS ultimately reducing the time spent with the patient? At what point does the operability of two disparate systems (office EHR and hospital EHR) talk to each other and the information I need is already in the EHR? Why isn’t all the information the patient needs sent home with her and she is told to bring that with her to her primary care doctor’s visit which, oh by the way, should be done within two weeks? Why aren’t all appointment made before she walks out the door? 

The form will not keep the patient out of the hospital. Communication will keep the patient out of the hospital. True coordination of care might keep the patient out of the hospital. More busy work for the patient’s primary care doctor will not. Since the order of the day is using hospitalists (a discussion on that is a post for another day) it is imperative that we improve our communication systems at the time of discharge and before the patient is seen again in the primary care office. Systems must stop thinking that one more form is going to save the patient. Especially another form on my back.


This post’s ending was rewritten on 10-10-2013 to take into account the multi-faceted reasons for the form.

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Google Glass in Primary Care

Google Glass is in its infancy, with over 8000 “explorers” who are eager to find compelling uses for it. The concept is cool: A hands-free cell phone that is voice activated. A month ago my healthcare social media friend Kathi Browne, who is a Glass Explorer, proposed driving to Louisville from Knoxville to allow me to play with Glass for two days.

Kathi Browne‘s Google+ site

I was excited to accept her generous offer. She was equally accommodating about spending two days in my home which is presently a construction area with two cats, to which she is allergic. She seemed to tolerate the experience admirably.

As expected with a beta product, we had a few setbacks. We couldn’t tether Glass to my iPhone unless I gave up my grandfathered unlimited data plan. That wasn’t happening. Next we tried using the local network in my office. When that didn’t work we thought we’d found an answer jumping on my MiFi. That was great until Glass went into sleep mode (which is frequent due to a short battery life) which disrupted the MiFi connection and I couldn’t get it back online until the battery was taken out of the unit. It isn’t easy to remove. Finally Kathi just handed me her phone and I stayed live on her account.

The main advantage over a regular smartphone is how surprisingly unobtrusive the device is, both to you and the patients. It’s easy for the wearer to ignore it except when in use. Patients were of three varieties–too polite to ask what was on my head until I brought it up and then not caring, knowing immediately what it was and wanting to play with it, and being unaware of the product but excited to learn about it. No one appeared worried and the first thing I told them on entering the room was that it was not recording.

While it’s easy to understand how surgeons, teaching physicians or ER personnel might use Glass, its implications in the primary care office are less clear. A few thoughts:

  • Glass is much less obtrusive than the laptop I carry or even the chart I used to carry. If I could dictate into the EHR this could enhance communication with patients.
  • Having a projection screen that would show the patient what I was looking at could be used for education, the way I sometimes use my iPad now. For instance, I had a patient with shingles on her back and I could project her rash or a reference rash for comparison. I can do that with my iPad now but that involves carrying an iPad and a laptop. I don’t use the laptop for education because the screen is awful.
  • On the down side, there is no unobtrusive way to Google a question using voice activation. My patients would know exactly how dumb I am. Wait, I already do that with them on the laptop so with Glass I could look cool and dumb.
  • In a rural setting, sending a picture or a video from the exam room to a specialist would be advantageous but no more than telemedicine could do.
  • Calling up an examination video for something I don’t do a lot of, like a specific orthopedic exam, could be helpful but I’m not sure about the patient’s reaction. They usually prefer to think their doctor is well-versed in such things. Back to cool and dumb.
  • It’s quicker to Google with Glass, an advantage over a cell phone.
  • The voice recognition is amazing. Odd names and medical terms were usually nailed on the first try. However, there didn’t seem to be a way to correct recognition mistakes.
  • I suppose patients would get used to it, but would they worry that I was secretly recording them?
  • As Clive Thompson commented in today’s New York Times[1], using Glass is uncomfortable enough that constantly looking at the little screen is not an option. That could improve communicating time instead of the way the EHR takes away from it.
  • How about an app in Glass that would identify a rash within certain parameters of likelihood? That is, a Watson for Glass. This was also suggested by Melissa McCormack of Software Advice in the Profitable Practice blog.
What I enjoyed most was the shear delight of several patients who wore it for a few moments. They were so excited by the device and its possibilities. Whether it will prove of use in the everyday practice of the primary care doctor remains to be seen.

1. Googling Yourself Takes on a Whole New Meaning http://goo.gl/WAAWki

Post was edited 9-4-2013 by request of Ms. McCormack to better describe her blog.

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A * Readable * Usable * Patient Note

It’s not just the clicks. It’s creating a Readable.Usable.Note.[1][2] It is embarrassing to look at a patient chart and read: “Your HDL (good) cholesterol is excellent but your LDL (bad) cholesterol is too high. I would recommend trying to reduce sure fact food intake.” What? Oh, yeah, reduce your fatty food intake. Or worse: “She wanted me to know that she had a laparoscopic hysterectomy and in for reck to me over the summer.” That one took a while to figure out. What I dictated was “she had a laparoscopic hysterectomy and oopherectomy over the summer.” Ouch. I read over my notes before I sign them but between the rush of seeing patients and the problem with editing your own notes within the horrible output that electronic records produce, it’s easy to miss your own mistakes.

The notes are built to maximize the billing that we do. But frankly, even though I revisit a patient’s chart and check their past medical history, update their meds, update their family history, review their social history, etc. IT DOESN’T NEED TO BE REPEATED IN THE NOTE! However, if I don’t rewrite all that, Medicare or the insurance company doesn’t believe I did it and I can’t charge for it. As a consequence everything is repetitive and finding the little gem of information one needs to care for the patient becomes more and more difficult. As anyone who has ever received the reams and reams of paper from an ER with an electronic health record (EHR) that has no discernible font changes or indentation can tell you, it is next to impossible to determine why the patient was there, what treatment they received and what followup they need.

To counteract this I dictate my medical reasoning in the discussion box at the end of the note. Next visit that’s where to look to find the important stuff. Of course this increases the amount of time documenting, taking away more precious moments I have to spend with the patient creating inelegant notes that are one step away from being worthless for subsequent treatment.

What if we could create two notes for every patient. One that went in to the billing records for auditing purposes and one culling the important stuff into a true “patient care note”. Surely there is software that could help us with that.

To quote Dr. Vartabedian: What do you think?

1. We need to reassess the patient note. http://www.kevinmd.com/blog/2013/08/reassess-patient-note.html
2. The doctor will see your medical record now. http://www.slate.com/blogs/future_tense/2013/08/05/study_reveals_doctors_are_spending_even_less_time_with_patients.html

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Be Careful What You Wish For

Physician-to-physician communication has become an increasingly difficult problem and its lack has worsened the fragmentation of healthcare today[1]. The challenge is complicated by many things:

  • Physicians lack the time to call colleagues about patients when their income is patient volume-based 
  • Fewer opportunities for direct physician contact, i.e. the doctor’s lounge
  • EHR systems cannot talk to each other
  • Patients don’t always tell their physicians about other doctors taking care of them
  • Printed EHR records are so full of verbiage that important findings are missed by the doctors trying to scan pages of unimportant documentation
  • Patients rarely carry their health histories with them in any format outside of memory
Another problem, at least in the healthcare system where I work, is the lack of a centralized area where physicians can come together to find community specific information. Blast emails are sent to doctors whose boxes are already full of “junk”, making it difficult to separate the wheat from the chaff. Recognizing this problem I recently approached the IT department at my institution. 

It was gratifying to me that they not only understood the issue, but were excited about assisting in a solution. My vision is to create a Physician Community where providers can go to find answers and communicate in a secure environment about any number of issues–problems with EHR, announcements, medical directors’ updates, calendars with CME and other dates of interest, blogs, CME, vlogs, links to outside trustworthy medical sites, and a place to crowdsource patient or system problems. IT gave me access to build such a community in a Sharepoint environment. 

Of course in addition to the problem of building the environment and populating it with what the doctors need, is getting them to use it. I feel certain that “If you build it they will come” does not apply in this situation. I envision needing to enlist lots of assistance from the President and CMO of the system down to the office managers and EHR superusers. 

I’m a firm believer that Social Media is the most important revolution in patient care today. Effective electronic communication between physician is part of that movement. But today, as I’m reading Sharepoint for Dummies, I can’t help but wonder–what was I thinking and can this make a difference? 

References:
1. Shannon MD MPH, Shannon. peg.org. January/February 2012. http://www.perfectserve.com/resources/docs/ACPE-PhysicianCommunication.pdf
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The Catch-22 of the Physician Champion Role

Yes, I’m a geek. When my girls were in high school, their friends were amazed that they received texts from their mother. One daughter has commented on Facebook that her mother is more tech-savvy than she is. At the beginning of 2012 my interest in the healthcare benefits of social media was born and I began blogging. I investigated and use LinkedIn, Twitter and Google+ while remaining attentive to Pinterest, AboutMe, Doximity, Instagram and others. So when my employer offered me the position of EHR Physician Champion for our physician group a couple of months ago, I took on the challenge. And challenge is the operative word.

Presently there are about 25 physicians in our 180+ multi-specialty group “live” (using electronic records). In a meeting specifically called to discuss “Provider Go-Lives”, three individuals tasked with implementing EHR turned to me and said, “So Dr. Nieder, how can we encourage doctors who are not embracing EHR to do so.” Hmmm….good question.

Let me preface these remarks by stating that our administrators have tried everything in their well-researched knowledge base to make this transition work. As we move forward improvements are made with every new Go Live. My immediate response was two-fold:

  1. In training, don’t give physicians the impression that using an EHR is using a paper chart in electronic form. It is an entirely new way to document and, unfortunately, the learning curve resembles third year medical school with IT support instead of attendings. It is every bit as daunting. 
  2. Encourage the doctors to shadow with someone already successfully using the system. 
The next question was harder. “What can we do to push the physicians who are balking?” Ah, therein lies the rub. Of course I recognize that the question was also my responsibility in the role of Physician Champion. To answer it, I was going to have to do some thinking. There are many reasons doctors give for not wanting to use EHR as posts by Palmd, HealthcareTechReview, MITTechnologyReview, and others attest but the biggest one in my system is that it slows down physicians whose salaries are based on productivity. 

My understanding of the value of EHR is simple enough–more legible notes, better population care using “big data“, enhanced patient care using clinical decision support tools, improved documentation to increase reimbursement, establishment of direct patient communication through portals, healthcare savings by reducing duplicate test ordering, and improved communication between providers in continuity of care. Even though our present system is poised to realize all these goals, the only one it is capable of performing at this very moment is legibility. So how can I convince physicians to use a tool that is going to slow them down (i.e. reduce their pay) and doesn’t yet have the necessary functionality to improve patient care?

As a geek, the EHR experience has me torn between two emotions: incredulity at its lack of usability  and that sinking sensation I remember from the late 80’s when the software rarely did what it was advertised to and crashed all too frequently, freezing the computer and forcing the user to restart both the software and often the entire system. The promise was there but the reality was long in coming. So too is today’s EHR. 
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An EHR Fantasy

Now that I’ve been using my EHR for more than three months, the muscle memory has taken over but there are still only so many clicks I am capable of doing in any given moment. Locating the right forms to insert, deciding how many templates to download, determining if I should plug the microphone back in between patients or carry it from room to room, figuring out the most expeditious way to document in the problem list from a scanned referral note or lab results and finding new ways to record a note, these things are all going to take a lot of time. Yesterday I came across an interesting article by Marla Durben Hirsch from the FierceIT blog: EHR vendors propagating a myth about their products. Amusingly enough, the article made me daydream:

I am in a room with a patient, iPad in hand. With touchscreen input, I easily target any templated buttons with my finger (instead of missing it with the stylus because it’s not quite in the ‘sweet’ spot). There is a graphical interface that’s pleasant to the eye, usable and intuitive. Dictation feeds directly into the chart from an adequately programmed microphone IN the iPad, so I don’t have to cart a separate piece of equipment with a ten-foot wire. There are separate modules for each specialist and a broader one for me, the family doc. If I misspell a word, there is a spell-checker (incredibly, something my present EHR is without). To show an illustration to a patient I simply double-click the home button and choose the browser for the internet or another app to illustrate a point. If there’s a video I’d like a patient to see it’s up in an instant. From the iPad I can quickly email links, videos or relevant information to the patient. It rarely crashes, the screen can be enlarged or reduced depending on my needs. It is smaller than a laptop and less obtrusive than paper charts. I add apps specific to my interests or my patients. And they don’t cost an arm and a leg. 

Alas I come back to the real world where my stylus still has to be placed just slightly to the left of the circle I’m aiming at. When I suggest to my IT support that hiring gaming developers might be a great way to improve the interface of our present EHR I’m really not kidding. Seriously, making patient documentation something inherently usable would go far to improve the acceptance of them with physicians. Despite claims to the contrary, physicians LIKE tech. We just expect the tech to be user-friendly. More specifically, we expect EHRs to work like the apps on our phones and our tablets. What a joy to look at a screen like this:

From the app iBP by Leading Edge Apps LLC


But no, my screen is riddled with tiny mono-color dots and clickorrhea is the name of the game. 


While patient care is serious there is no reason why electronic documenting could not be a joy to use. As more digital natives enter medicine they will be more insistent that the software they use to take care of patients be as easy to use as the apps they use to monitor their heart rates with exercise, check in with Foursquare, or text their friends. From my perspective, they can’t get here fast enough!

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The Three “P”s of Mayo–Patient-centered, Physician-led and Collaborative Partnership

Last week I attended the Mayo Clinic’s Annual Social Media Summit in Rochester. What most impressed me had nothing to do with the conference. On Tuesday afternoon before the Summit began I toured Mayo Clinic. It was supposed to be for an hour but lasted more than two because our group, consisting of one doctor and nineteen PR professionals, was so interested in the information being fed to us. I don’t know why the publicity folks were so intrigued, but for me Mayo’s philosophy of “patient-centered, physician-led” care hearkened back to a time when the patient-physician relationship was inviolate. It was stimulating to realize that my instincts of how medicine is best-practiced are right on target.

My myopic opinion regarding the fragmentation of healthcare sees the destruction of the patient-physician relationship by multiple entities, who are primarily interested in a piece of the economic pie, as central to our healthcare mess. At Mayo, no project moves forward unless there is a physician who champions it and it is the physician’s responsibility to ensure that every project is dedicated to improving some aspect of patient care. Physicians are salaried so they spend the time necessary to care for patients and are not incentivized to increase the numbers of patients seen or do procedures to enhance the bottom line. 

Every person I met who worked for Mayo reiterated the importance of putting patient care and comfort first. It was incredibly refreshing. The Mayo logo emphasizes a patient-first policy as well. I’d seen the logo multiple times but somehow never thought about what the three shields represent. Our tour guide explained: Patient care, research and education. The educational aspect was obvious as we walked multiple floors of patient care areas. I noticed no TVs in patient waiting rooms but many had computer screens where patients could learn about their conditions. It is a refreshing and calming atmosphere without the cacophony of media noise. There is art everywhere. Waiting rooms are spacious and well-lit. Meditation rooms and educational spaces abound. 

Children’s waiting area


Mayo has always represented excellent healthcare in my mind. Patient reports that come to me after a visit there are extraordinary due to the extent of the integrative care the patient experiences from multiple medical disciplines coming together. I expected to be impressed. I did not realize I would also be reassured. Putting patients first is what I’ll continue to strive to do, despite insurance interference, governmental policies or EHR dysfunction.


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Post-its and the Practice of Medicine

Ever since the first Post-its® appeared in the early 80’s I’ve used the little colored sheets to remind myself about all kinds of things–telephone numbers, todo lists, shopping lists, dates to remember, notes for other people-especially my husband. I do not know how my mother, with her organizational genius, managed to survive without them.

When I began using a superb productivity program called Omnifocus, I thought my Sticky Note® penchant would be reduced. However, with the advent of EHR, I find it has done anything but. They clutter my desktop (my REAL desktop, not the one on my Mac) with quickly scribbled suggestions for changes requested or features not found on Allscripts (our EHR), thoughts for the blog, thoughts for future Vlogs, need for specific patient information, a book or website suggestion from a patient or my grocery list as I dream up an idea for supper tonight.

Later in the day I will quickly go through the stickies and move them to my calendar, Omnifocus, or if possible I’ll “just do it” (using a time-management technique by GTD® guru David Allen). They are ubiquitous in my exam rooms for writing quick info down with patients–a web site, recommended reading, an address, or medical term most often. Almost as frequently, they remind me to do something for a patient that would take too long to enter into the Electronic Health Record (EHR) or more commonly, it’s unclear where to put it in the EHR–like getting old records out of storage, obtaining recent ER notes, or looking up some particular disease state to research for the patient.

It’s clear that most other forms of paper will be disappearing from my office. Already the huge stacks of charts are disappearing, replaced with tasks or scanned documents in the EHR. Slowly, I’m beginning to appreciate the uncluttered appearance of my desk. However, I’ve found that its glass top, something I never used to see, makes a great surface for sticky note adhesive. 

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Guest Blog: A Patient’s EHR Point-of-View

Barry Comer, blogging at Thoughts/Rhythms, gives a poet’s impression of the EHR experience:
In June of 1966, several crew members begin dying from a mysterious depletion of salt, extracted from their bodies. The crew’s doctor anaylizes post-mortum and discovers by instrument, the phenomenon’s cause. 

Of course this is the fiction in 1966, envisioned by Gene Roddenberry for the 23rd century. The imaginary “tricorder” in the doctor’s hands is for wishful dreamers and possibly envied by my physician, in 2012. 

With the introduction of electronic medical records (EMR) to the patient/physician dialog, neither the future nor a “diagnostician in a hand” have arrived. Clumsy to learn, intrusive in use, EMRs in form and function are short-reaching obstacles, that chart their course with manual input and uncertain results. 

Some tools in the 21st century disappoint and others appear with malice. Because EMRs are still untamed and newly minted, their usefulness arrives as a mixed blessing. 

They say, “time heals all”, but our relationship is in trial to stay in the moment.

My physician is intuitive, intelligent and listens carefully. She possesses a black belt
in medical counsel, that appears clairvoyant. Her holistic relationship to my body and mind is why I call her my doctor. The EMR pushes that trust backwards. It conspires to break her gaze from me and worse, has taken certainty of our relationship, into the “getting to  know you” process again.

Not only do I depend on her words, I put trust in her eyes. But when they stray, I feel the magic leave by the tiny keystrokes and space bar taps, filling the exam room. Our agreed upon relationship is breaking and hear it in her sigh.

This was not the future promised and feel once again, that some technologies are better left in clinical trial, with release contingent on both aesthetic and functionality. Without both, advancement seems muted by imagined giggling of software authors in the bushes. 

Not all things advanced by the goalkeepers make for better analysis and savings. Growing suspicious has been supplanted with hopeful resignation. It may get better and after all, 
I may just have a cold.    
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Continuous Partial Attention

Continuous Partial Attention–while reading a blog post this morning that term jumped out at me. The last few weeks of juggling a laptop while talking with patients have made it obvious how easily distraction can take away from the doctor-patient interaction. Right now the computer interferes with my ability to give complete attention to my patients’ stories. Did I have the same problem way back in third year medical school when my first ? I don’t recall taking pen and paper in patient rooms back then, but do remember trying to juggle all the things I needed to ask–chief complaint, history of the present illness, past medical history, family history, medications. Then there were things that needed to be looked at–vital signs, physical exam, nurses notes, ER notes–followed by the assessment and plan. These were all foreign terms and workflows to me. Was I intensely listening to the patient then or more likely, worrying about what I’d forgotten to ask, or do, or write down or study? My earliest instance of Continuous Partial Attention (let’s call it CPA so I don’t have to keep writing that term) with patient care must have begun then.

Early in practice I found ways to control the CPA triggers–a snack of nuts or fruit around 10 am to keep my sugar from dropping out; keeping the phone on silent (there are medical programs on it that I use routinely so I can’t leave it on my desk); using meditation techniques to bring me back to the patient if I find my brain wondering off; exercising and sleeping routinely so I have enough energy for my day.

It’s not just doctors who have the CPA issue. Many times I recognize the same thing going on with the patient–the gentleman this morning who needed to be at work and was only half-listening to my advice regarding his medication and exercise compliance, the woman who thought bringing three kids to her physical was a good idea, the patient who was recently diagnosed with cancer and nearly oblivious to any other health concerns, or the husband with a terminally-ill wife paying little attention to his own health (or me).

Surely the CPA will fade away as I find a path to making the electronic record become as unobtrusive as the paper one once was (hint to IT dept–smaller tablets would help with this…just sayin’). In the meantime, one of the more important lessons on the EHR learning curve is finding a way to move the laptop out of the center of the conversation–figuratively and literally.

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