Patient response to Electronic Records

Amazingly my patients have had a very patient response to the introduction of EHR (Electronic Health Records) to our office. They sit and watch me type and curse with an air of amusement and calm. More calm than I am feeling.

Yesterday began our third week of EHR. Muscle memory has kicked in and I saw 15 patients without running too far behind. Seeing 20ish patients daily again is starting to look feasible. Someone walking into my office no longer has to look over mounds of paperwork to see me. My only concern is whether my employers will cease to understand how much work I do if they can no longer see the physical evidence of it.

On an up note, there will soon be a couch in the area where the credenza is now. Since my colleagues warn me that it will continue to take longer to finish my charts it seems reasonable to have a comfortable place to do so. The main purpose of the credenza was to support the hundreds of charts I needed access to on a daily basis. The staff is very supportive of the change as well (wonder why…).

Many patients have followed me over the 25 years I’ve been in practice. While little has been different in the exam room until now, there have been lots of other changes–two previous locations, private practice to employed doctor, hospitalists, urgent care centers, and oppressive insurance controls to name a few. For the first time in two weeks, I was able to gauge patient reactions to this new-fangled way of documenting. Prior to yesterday I was too bogged down with clicking boxes, losing screens, figuring out where to put a new symptom the patient just threw at me, finding templates and vital signs and generally being absorbed by the Allscripts system to observe my patients (and please don’t make me worry about what I may have missed in patient care over the last two weeks while I followed this steep learning curve).

Now I carry this new contraption in the room:

My younger patients hardly notice it. They would not have commented had I not explained its newness and why it was taking a little longer to enter information than usual. Older folks regarded it with expressions ranging from dismay to perplexity. Most of them commented before I did.

  • “Do you like it?” 
  • “Do you think it will ultimately speed you up or slow you down?” 
  • “How hard is it?”
  • “Did Baptist (my employer) force you to do that?”
  • “What happens when the system goes down?” (I wonder about this one myself)
No one seemed particularly surprised or overly worried about my use of a computer to document their visit. They all seemed impressed when I stood up and said that their prescriptions were already at the pharmacy. 
At the end of the day what most impressed and humbled me was the sense that within their acceptance of this new device was a trust that regardless of the way I document their care, it would still be delivered in a way helpful to them.
At the end of the day, that’s what it’s all about, isn’t it?
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The Need to Blame the Doctor, not the System

Maureen Dowd wrote a thoughtful and thought-provoking article in the New York Times this morning entitled “The Boy Who Wanted to Fly“. I had read about the incident in a twitter-linked article earlier in the week and my heart ached for everyone involved–the boy, the parents, the pediatrician, the ER docs and the staff treating him at the hospital. I know from professional experience how gut-wrenching this outcome is to the doctors and staff involved. As a parent I prefer not to imagine what the personal experience would be. It was hard enough to have stood beside friends as they moved through it.

Many of the comments below the article demonize the physicians involved in the care of this boy. That is an easy thing to do and seems to be a particularly American way of approaching a problem–find someone to blame and sue them. Unfortunately, this will do nothing to fix what is an increasingly common problem in our healthcare system today.

I don’t know the specifics of what happened in this case. On the surface of it, the article and remarks about it emphasize many of the issues of our broken healthcare system. The comments engendered begin with ‘hard-hearted doctors” and “sue the jerks”. Perhaps the most thoughtful was the comment by Infectious Disease specialist Dr. Jonathan Rosenthal who said: “The average physician will never see a case of florid Group A Streptococcal septic shock such as this one in her entire career. One of the reasons these rare cases can be so lethal is that is can be enormously difficult to pick them out from among 10000 cases of viral illness in a Pediatric ER. Herculean efforts are made every day not to miss early sepsis. We can learn from cases like this but not if we are distracted by looking for the person to blame. This poor child was seen by a number of physicians – were they all incompetent?”

As a primary care physician some of my thoughts are: How busy was the pediatrician? How busy was the ER? Did they have the time and experience to pick up on those “soft signs” of sepsis that Sully Sullenberger alluded to? As an aviation safety expert he understands the importance of fixing the SYSTEM that is causing the problem, rather than placing blame on the individuals involved.

Patients live in a world where physicians are pushed to see more and more of them to pay the bills; where technology substitutes for stopping and really “seeing” a patient as more than a disease state; where the patient is seen only as a dollar sign by the healthcare administrators, insurance executives, employers, lawyers and politicians who crowd into the examining room as if they had a sacred right to be there; and where time, the most important commodity for good patient care, is stripped from those on the front lines because it is not valued highly by their own peers.

This case should be a rallying cry for patients (and we are all patients) to fix a badly broken, fragmented healthcare system where volume and technology substitute for care. Since this involves a political fix from a system equally broken and fragmented, a fix that must involve compromise from both sides of the aisle, I fear for the future health of my patients and my profession.

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I Thought I Just Explained That…

Helping patients to understand the effects of lifestyle on risk-factors, explaining lab results and discussing disease processes, that’s all part of my job, right? Patients go through their lists and we discuss strategies for improving their health. When they have a disease process we discuss alternative therapies, causes and second opinions. I use a white board which the patients seem to like, for writing down important points or drawing anatomy or sometimes just suggesting a book I think they’ll like. I love the idea of participatory medicine and have “taken the pledge” to make this a priority in my practice. I’m blogging and tweeting and watching other blogs. I think I’m pretty good at making sure the patient understands his or her medication, disease, and followup before they walk out the door. Then a patient comes in and knocks me for a loop.

After a long discussion with a young woman regarding what I thought was an allergic reaction she walked back to the waiting room where my office staff overheard her say to her mother, “Dr. Nieder has no idea what this is and doesn’t know what to do for it?” WHAT?!?!???!?!?!? Honestly I spent a long time discussing what I thought had caused her reaction and how to treat it over the next couple of days. It was not severe enough for a prescription so did she think that without a medication she wasn’t “really” being treated? Was the fact that her presentation was puzzling and I was unsure to start make her think that I never put the puzzle pieces in place? Thank goodness her mom asked to speak with me!

Makes me wonder how many times I think I’ve been communicating just fine, when in reality what I’m saying sounds like all the adults in the Peanuts videos.


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Patient-centered Care

The New England Journal of Medicine published an opinion piece this week entitled “Defining ‘Patient-Centered Medicine“. Now to those of you who are fortunate enough to have avoided time in the ER, hospital or multiple doctors offices, this may seem obvious. All care should be patient-centered, right? After all, that is what it’s about, taking care of the sick person or helping a well person stay that way. For the rest of us, who have had the misfortune of being ill or helping a loved one navigate our healthcare “system“, it is obvious that we could call our system “insurance company centered” or “healthcare provider centered” or “government centered” or “pharma centered”.  Rarely does anyone stuck in the middle of a disease process entailing many specialist and hospital visits feel like they are the center of the medical universe.

At its best, a patient-centered therapeutic milieu would consist of a supportive environment where communication is the highest value followed by caring, well-trained, humble providers who are not impeded by the needs of profit-driven pharma, insurance companies, hospitals or providers. As anyone who has made the journey will attest to, if you are going to spend an extensive amount of time in our health care system, you need to be a well-informed self-advocate OR have an advocate beside you every step of the way. You need to question every doctor and nurse that treats you unless and until you are sure they deserve your complete trust. And we “healthcare providers” need to be open to the questions and do our best to answer them and find specialists who are not offended or unnerved by the questions. Patients and doctors must provide the “push back” necessary to change this system for the better.

It is hard to get past the avarice of the many entities involved and see a better way of treating patients, but a dash of common sense would sure improve a lot of the system problems I see every day. To quote my favorite again: “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.” William Osler MD

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