The Art of Medicine CIO Breakfast - What Needs to Change to Get Doctors Back to the Patient?

Medicine is part science.... Part art.

The relationship between physicians and patients is at the core of healing. This begins with hearing and understanding. We want to reimagine healthcare—where physicians can get back to the art of medicine and were delighted to be joined by panelists:

Dr. Mark Kelemen, Senior Vice President, CMIO, University of Maryland Medical System
Dr. Charles H. Bell, Vice President, Advanced Clinical Applications, Hospital Corporation of America (HCA)
Stuart James, CIO, Sutter Health
Dr. Andrew Watson, CMIO, University of Pittsburgh Medical Center (UPMC) (@arwmd)

The panel was moderated by our very own
Dr. Paul Weygandt, Vice President, Physician Services, Nuance
Keith Belton, Senior Director, Clinical Documentation Solutions Marketing, Nuance

and attended by some 50 attendees with varying backgrounds and perspectives

The underlying question:

How do return the focus to the patient. How can physicians navigate the changes and challenges of today’s complex healthcare environment while doing what matters most to them – listening and caring for patients?

The panel discussion addresses current physician frustrations with technology and what needs to change to keep them focused on patients and not data entry. It was clear that the physician’s voice and medical decision making is what matters most in practicing the art of medicine and how do physicians and patients both benefit?

 We know from surveys that

• 36% of physicians say that EHRs interfere with face-to-face communication during patient care
• 80% of physicians say “patient relationships” are the most satisfying part of practicing medicine
• 28% of an average ER physician’s time is spent directly with patients
• and from a recent HIMSS session interesting Patients prefer doctors to have an EHR

This is about the changing face of healthcare – it’s not just about technology. It’s about how we envision healthcare. How do we explain to providers that this isn’t about technology – this is about a new world order coming to healthcare

Posting every patients Magnesium level multiple times in a note is not good clinical care #artofmedicine #himss14

One of our panelists asked the audience:

How many Docs would go to facility with no #EMR and used paper - no hands went up

We do see value in Health Information Technology

One of the overriding concerns was the need for cultural change. The office or hospital based physician system is struggling to meet the patient needs today. They want to have the right nurse or physician there for them at the right time and indeed at the right place with telemedicine. It’s about cloud-based/consumer-based healthcare.

More consumer-friendly healthcare

We need to get back to that local physician practice – with technology in the middle as a supporting actor but not the main event

Technology cannot be an impediment to taking care of patients

Many physicians are in this field because we are trying to drive change but are struggling with the existing system that fail them. When I see a patient I have to review 10 systems, carry out at least 4 major systems examinations before I can submit a claim that properly reflects the care I delivered:

 I am not taking care of the patient I am taking care of a computer

Dr Andrew Watson told the story of a patient under his care with a terrible antibiotic resistant infection that a patient developed in hospital and he was now under constant supervision adn intensive therapy. But as he said - he never needed to come into hospital - he could have been treated at home. Poignant reminder that Telemedicine is not just about reducing cost - it can be better for the patient and offer better results.

Dr Bell is waiting for the MIDI (musical instrument digital interface) moment so that he can plug into the medical record and go.

As a musician he remembers the implementation of the MIDI interface in the early 1980’s that allowed music manufacturers to create one standard that was royalty free and widely adopted for the benefit of the user musicians and the vendors. He wants that in healthcare - so do I.

Until we change the mandate on clinicians to document 8 of 10 systems to be fairly compensated for the care given  

And importantly the concept of Bring Your Own Device (BYOD) is bringing functional tools into the healthcare setting and will/is revolutionize the care being delivered. As one panelist put it:

my iPad never complains, is always there, has the latest information and access to latest medical updates

To summarize:

• We need strategies for bringing the focus back to the physician-patient interaction and removing impediments to that relationship
• Healthcare organizations should be and are encouraging/valuing physician professionalism
• This is about the changing face of healthcare – it’s not about technology. It’s about how we envision healthcare. How do we explain to providers that this isn’t about technology – this is about a new world order coming to healthcare

Come join the conversation at The Art of Medicine or come to the panel session Thursday, March 27, 2014, 9:00 - 11:00 am EST at the W Hotel,100 Stuart Street, Boston, 02116

Physician Symposium #DrHIT #HIMSS14

The Physician (#DrHIT) Symposium at #HIMSS14
Opening session was eloquently covered by Robert Wah, MD (@RobertWahMD) detailing the spectrum of issues ranging from the new Healthcare System:

The challenge of SGR “fix(es)” and the evolution of the systems we are implementing and the value proposition. As he put it

Quality of care is improved with better information — saving lives and money

But Health Technology is not easy to implement:

Health tech is hard, but harder part is changing #workflow & #workforce. @RobertWahMD#HIMSS14#DrHIT Org alignment: pic.twitter.com/AQsX1a3846

— Wen Dombrowski MD (@HealthcareWen) February 23, 2014

And layered on top is the increasing challenge of securing the data with hackers seeing healthcare data as 15x more valuable than financial hacked data!

MT @CraigJoseph: #DrHIT@RobertWahMD Arms race btwn those trying to protect patient data & those trying to get it. Who'll win? #HIMSS14

— HIMSS (@HIMSS) February 23, 2014

What we need is coordinated care and Dr Wah offered this visual of the way forward

Christine Bechtel focused on the Activate Evidence Based Patient Engagement and as she reported - Patients like doctors who have an EHR

Patients think EHRs help doctors deliver better care

• Timely access to information, sharing info across care team, med history, managing health conditions
• Overall, EHRs were rated between 23%-37% points higher than paper on these elements

Interesting since doctors have been reported as saying they dislike the EHR but patients like seeing their doctors with an EHR

MT @drnic1: 80% patients say online #EHR access improves #health and a reason to stay with a practice. #DrHIT#Himss14#HITworks

— HIMSS (@HIMSS) February 23, 2014

The sad thing was this session was concurrent with @ePatientDave in another room - The Connected Patient: Learning How Patients Can Help in Healthcare only social media united these sessions

@cmaer@ePatientDave Missed opportunity - would be so much better to have those two intersecting rather than in parallel #DrHit#HIMSS14

— Susan Shaw (@drsusanshaw) February 23, 2014

As for Jonathan Teich and his session Improving Outcomes with CDS - he used his personal experience where peer pressure (as he described it 3rd time he was pressured to take on an expert triple diamond ski slope) he finally agreed and ended up in a serious ski accident fracturing multiple vertebrae. Interesting analogy relative to the Clinical Decision Support System and the pressure this applies to clinical practice sometimes inappropriately...
Interesting look at alerts and the potential for providing more than just alerts but actually providing intelligent data that distill down to 10 types of CDS interactions

1. Immediate Alerts: warnings and critiques
2. Event-driven alerts and reminders
3. Order Sets, Care Plans and Protocols
4. Parameter Guidance
5. Smart Documentation Forms Improving Outcomes with Clinical Decision Support: An Implementer’s Guide (HIMSS, Second edition, 2011)
6. Relevant Data Summaries (Single-patient)
7. Multi-patient Monitors and Dashboards
8. Predictive and Retrospective Analytics
9. Filtered Reference Information and Knowledge Resources
10. Expert Workup Advisors

And the important summary slide was the CDS Five Rights (Right information, people, formats, channels and times)

And returned to one of the core opportunities - Patient Engagement with a a session by Henry Feldman, MD FACP: Informatics Enabling Patient Transparency. He asked the same questions as another presenter - how many fo the audience considered themselves a patient (Still only a shabby 80%) and then took this further asking

• You feel that you know exactly what your provider was thinking in making his decisions
• You think the clinical systems helped your provider understand comprehensively everything about you
• You build clinical systems or are a provider
• With the inevitable decline in hands up
• You think your (or anyone else’s) software truly helps the patient or even the provider understand comprehensively or transparently what is going on

Sadly we are not near this and the reality is much further with physicians thinking patients are unsophisticated. Yes at he pointed out the airline industry gets it and even the DMV/MVA gets it offering customer engagement models:
Their experience and stats blow the unfounded resistance out of the water

• Only 2% of patients found notes more confusing than helpful
• Only 2% found the note content offensive
• 92% said they take better care of themselves
• 87% were better prepared for visits

Importantly we need to turn data into information for patients and he cited the Wired example of a Laboratory test (Blood Test Gets a Makeover Steve Leckart) and the makeover for
Basic Labs

Cardiology Result

and the PSA result

I know where I'd like to be receiving my care (and lab results) from! Great finish to the session. So as he summarized where we should be with patient engagement an data

• Open your data to your patients
• Patients understand more than we think
• Teach patients how to use data effectively – This can save you time in the long run
• Put your patients to work on their own health!
• Vendor work on how patients will view big data
• It’s a new drug, research the risks and benefits

Great start to what will be a busy HIMSS

Art of Medicine at #HIMSS14

The new Art of Medicine campaign is focused on getting physicians back to their original roots - the reason we all stepped over the threshold of medical education and into an honorable profession to serve our community. Its all about the patient but changes in the healthcare system and in particular changes with technology have taken the focus away from our patients and onto the technology in our office. Recent study conducted by Northwester University highlighted the distraction physicians feel away form their patients by the EMR

As Steve Schiff, MD a practicing cardiologists puts it

As far back as I can remember, there was never a time when I didn’t want to be a physician. It’s a choice in which there is no equivocation: either you want to be a doctor or you don’t.

The campaign includes an e-Guide: The Art of Medicine in A Digital World replete with thoughts, suggestions and concepts to manage the digital world while remaining focused on the most important person in the examination room - the patient. The release was covered in this piece by HIT Consultant and referenced the panel taking place next month in Boston.
Many of the thoughts and ideas were captured in the Top 38 lessons from Digital Health CEO’s from Rock Health. I picked a few choice quotes that capture the spirit and intent fo the Art of Medicine for me:

“Healthcare is yet to be transformed by technology.” - Joshua Kushner
“You need a degree of foolishness to cause disruptive change in healthcare. Dare to dream.” - Vinod Khosla
“If you’re going to re-invent healthcare you have to start from scratch.” - Vinod Khosla
“The key to good product is invisibility for the user.”
“Partnership is going to be absolutely key to taking healthcare to the next transition in evolution.” - Sue Siegel

  The campaign kicked off this week with this resource page - The Art of Medicine and a short video highlighting the challenges and opportunites

There will be much discussion at HIMSS14 around the topic and we are looking forward to hosting the panel on Thursday, March 27, 2014, 9:00-11:00 a.m. at Boston’s W Hotel. You can find out more and/or register here or come by our booth 3765 at HIMSS14.

“The science of medicine goes nowhere if you leave the human element out of the equation. Curing our patients starts with listening to them.”

Are Physicians the Cure to Healthcare’s Bugs?

This post originally appeared on HIT Consultant

During a recent and troubling discussion with a physician friend, he described to me a new ailment he’s been experiencing: waking up in the morning, and not looking forward to going to work.  The reality is that he is not alone.  It’s no secret that physicians across the country, regardless of their specialty or location, are reaching their limit for juggling new requirements, technology upgrades,  and policy changes, all while trying to deliver personalized, quality care to their patients.  As a result, busy physicians are, quite understandably feeling pressured and pulled away from direct patient care and critical clinical-decision making, and, at the end of the day, that is what matters most to patients and physicians alike.  
It is easy to imagine the impact overloaded and dissatisfied physicians could have on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and how these regulatory pressures and so many new healthcare technologies could be linked to the decline of the “art of medicine.”  But are we, in fact, misdiagnosing the problem?

A recent study from Johns Hopkins University found that internal medicine interns are lacking proper bedside etiquette, which is not only essential to providing quality care, it directly impacts medical outcomes and patient satisfaction scores.  Focusing on five key elements of proper patient-physician decorum, researchers tracked whether or not hospital interns:

1. Introduced themselves, 
2. Explained their role in the patient’s care,
3. Touched the patient,
4. Asked open-ended questions, or
5. Sat down with the patient during the visit.  

Results revealed that interns touched their patients (either during a physical exam, handshake or gentle, supportive touch) 65 percent of the time and asked open-ended questions 75 percent of the time, but introduced themselves only 40 percent of the time, explained their role merely 37 percent of the time, and actually sat down during only nine percent of the visits.  Such results are disconcerting, at best, and reveal a more pressing truth: These basic and critical communication deficiencies that are essential to providing holistic patient care are not being taught.

The study exposes the reality that the shift away from patient focus and the “art of medicine” isn’t just stemming from increased physician workloads caused by new policies and changing technologies.  It is infiltrating our profession through a change in training, as well.  While we have reduced junior doctors’ work hours for safety reasons, we have not adjusted the overall length of training they receive.  Medical students, our future physicians, are not receiving the holistic education that helps them balance keen scientific skills with compassionate delivery.

But, as they say, “knowledge is power,” and now that we are starting to pinpoint conditions that are tearing at our profession, we can start to heal them.  We can’t expect our medical interns to know how to handle difficult and emotional situations unless we show them.  We need to teach them how to engage with patients, earn their trust, really listen and understand them.  They need to be able to view what their patients say through both a  lens of science and medicine, as well as  a  lens of compassion and caring, in order to help them get and stay well.

And what of the technology challenges that are driving wedges between patients and physicians?  While there is no denying that much of health information technology is putting pressure on physicians and forcing them to adapt to new methodologies, these challenges are a necessary to revolutionizing patient care.  They are, in essence, the basis of growth and the very nature of science.  If it weren’t for boldly trying new approaches, we might still be relying on leeches and blood-letting to cure melancholia.   Just as we can’t expect a patient with heart disease to know intrinsically to maintain a low-sodium diet, we can’t expect the healthcare industry to know how to fix everything unless we speak up and advocate for change (especially with the other loud voices of insurers and politicians speaking on “our behalf”).

We must be mindful that as physicians, it is our sworn duty to defend the practice of delivering the best care to our patients from anything that threatens to impinge on that quality.  We need to stay engaged and be responsive; and that also means we need to assist with diagnosing major technology pain points and identify when something isn’t working.  We have the rare opportunity to shape the future of healthcare infused with technology and I, for one, want to be part of developing a solution that helps the next generation of physicians offer that comforting touch as they deliver an even greater level of care to their patients.

Clinical Documentation in the Electronic Health Record

Many years ago I remember an excited friend who worked for one of the vendors of electronic medical records (really this was more of a billing and patient tracking and management system than and Electronic Health record) desperate to show me some of their new applications – in particular a module they had developed to capture clinical data. He pulled out his “laptop” (it was more of a luggable)

Fired up the application, selected a patient and proceeded to enter a blood pressure: click, click, click, click, click, click, click, click…..some 20 clicks later he had entered a blood pressure of 120/80. He was excited and I was not.
I am constantly reminded of this as I watch doctors interact with systems and especially with the ongoing focus on blood pressure (Did you know that May is the National High Blood Pressure Education Month) and the video challenge from ONC

“To create an under 2 minute compelling video sharing how they use health IT or consumer e-health tools to manage high blood pressure”

The winners can be seen here
Key to the challenge is having the data for monitoring as emphasized in the Six Sigma techniques of DMAIC

• Define
• Measure
• Analyze
• Improve
• Control

Capturing that data without burdening our clinical staff who should be focused on the patient not on intrusive and distracting tasks of data entry. I made this point a number of years ago "Doctor Please Look at Me not Your EMR" that came from a personal experience in our local practice and as my then 10 year old succinctly put it at the time

“I wish the doctor had spent as much time with me as she did with her PC”

But data is essential and getting this into our medical record is essential to derive the value from these systems. So the study published in Journal of the American Medial Informatics Association (JAMIA): "Method of electronic health record documentation and quality of primary care" who’s conclusion implied that dictating clinical notes “appeared to have worse quality of care than physicians who used structured EHR documentation”.

Digging into the details suggested this was based on old data (2004 – 2008), measured the quality of documentation not the care and that choice in tools is the key to success in EHR implementations and clinicians satisfaction

There are good reasons that dictation as a means of capturing clinical documentation has been so successful for such a long time – it is easy to do, efficient and saves time. But the gap between the narrative text created and the clinical data we need to manage our patients widens with each report created. The JAMIA report highlighted the impact this can have on care, offering some insight into the potential decrease in the quality of care that results in disconnecting the clinician from the interaction and clinical decision support tools and data that is built into the EHR. But the process of entering this data must not intrude into the clinical interaction with patients. All is not lost – Natural Language Processing (NLP) tools are bridging this divide allowing clinicians to use their preferred method to capture the patient’s clinical information in narrative form and extracting out the discreet data that is essential for the EHR systems that need the data to drive the decision support tools and workflow processes.

So clinicians can have their cake and eat it too and best of all it allows them to return to the art of medicine and focus on the patient not the technology.