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Re-imagining the EMR:  Three essential and transformative innovations for caregivers in value-based world.

Posted by Dan Mazanec, MD on Oct 26, 2016 3:16:29 PM

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The transformation of the U.S. health care system to a value-based orientation based on evidence-informed practice and patient-centered outcome metrics is accelerating. The EMR is central to this process but current technology simply hasn't kept pace. Physician burnout is epidemic in today's health care system. Depending on specialty, 40-55% of doctors reported symptoms of burnout in a recent survey describing loss of enthusiasm for work, increased cynicism and a decreased sense of personal worth. Frustration with dated, antiquated electronic medical record technology is a major contributor to burnout as increased computer data entry consumes precious time better devoted to genuine patient care. A just-released survey of more than 15,000 practicing physicians on EMR use found 57% reported decreased face to face time with patients. In comparison with 2014 data, more physicians (27%) reported serious dissatisfaction with the electronic record. 64% of doctors in their most productive years (aged 46-55) noted the EMR slowed their workflow.

More time spent at the keyboard steals from time with family or restorative recreational activities. In addition to spawning an entirely new health care specialist - the scribe - as a workaround for poor technology, EMR-related burnout is leading to early retirements, career changes, and ultimately decreased access to care.  

Here are three essential features - "must haves" - which should serve as the guideposts for design of innovative health care technology that really works best for clinicians and patients in the new world of health care:

 1. Enhanced ease and accuracy of documentation 

The core of medical practice is the physician-patient relationship, built on communication, empathy, and physical touch. Neither doctors, nor patients are satisfied when clicking away to complete the note in the EMR is the focus of the visit. As Drs. Gardner and Levinson have eloquently stated in their recent op-ed, Turn off the computer and listen to the patient, "medicine is buckling under the weight of massive, ill-designed electronic information systems." The solution is to the make the patient the center of the encounter and not the computer keyboard.  

Certainly with 21st century technology we can be more creative than pulling a scribe into the exam room to do data entry. Heath care must be one of the few areas where technology has actually increased user workloads, requiring the addition of thousands of new employees just to stay afloat. Beyond the added cost, there is a risk of intrusion on the doctor-patient interaction as a scribe's presence may inhibit sensitive patient-doctor discussions. A doctor-patient relationship with open, comfortable discussion of the most personal and private issues is central to delivery high quality care with the best outcomes. 

How about transcription of dictation using voice recognition technology? While seemingly easier and more efficient that clicking away at a keyboard, there is growing evidence that transcription errors are frequent and pose a risk to patients. A recent report of transcription errors in a busy emergency room practice examined a random sample of 100 notes dictated by attending physicians. Almost 15% of the 128 errors identified were deemed "critical." The Joint Commission has commented that the error rate may be as high as 22% and described a malpractice verdict of $140 million in a suit involving a transcription error resulting in the death of a diabetic patient. 

As the greater tech universe has rapidly moved from PCs and desktops to mobile devices, health IT needs to aggressively expand the role of mobile - tablets and other mobile devices as clinical tools. Recent studies using a tablet computer linked to the EMR in both outpatient and hospital settings clearly demonstrate improved provider efficiency, increased face time with patients and improved patient satisfaction. When asked specifically about the device, clinicians rated portability the most important feature, allowing for documentation at their convenience and shortening after clinic hours in the office. Touchscreen data entry was ranked second.

 

2. Clinically relevant information in a useful format 

A less well known weakness of the current EMR is the final product - the clinical note. From the early days in med school, we all learned the bedrock of the patient encounter is a careful history and physical exam leading to an assessment and plan. This process culminates in the clinical note encapsulating the problem, the diagnostic thought process, and management plan. The initial note "tells the patient's story" and is central to communication to all caregivers for the patient. Over time, serial "progress" notes document the patient's course and reflect changes in clinical thinking and adjustments in the treatment plan. With the advent of the EMR, this time-honored and tested, elegant and effective approach has been replaced by a "file cabinet" mentality producing "nonsense notes" consisting of pages of checked boxes and lists of ICD-10 coded diagnoses and orders. Current EMRs were built to address meaningful use documentation requirements and to support optimized billing. Not surprisingly, in the clinical note of today's EMRs, the patient's problem and the caregiver's thinking are often lost in a morass of irrelevant information.   As a consultant and recipient of many such notes, I can attest they were usually worthless from the standpoint of patient care. Reviewing a 2" stack of paper to find a few meaningful sentences describing what's been done during a prior episode of care is not a rarity in medical practice today.

What's needed is a concise note that highlights relevant, clinically important information capturing the individual patient's narrative including psycho social and behavioral issues. Front-line caregivers must be involved from the beginning in the software design process of the next generation electronic record to insure that what's really important for patient care is documented. Smart, innovative EMR technnology should improve patient care and physician efficiency by facilitating easy access to previous clinical information including medications, laboratory tests, and imaging.   Current EMRs commonly provide a "problem list" representing a compilation of all recorded diagnoses. Much more than a static problem list, state of the art health IT should creatively and concisely display the historical trajectory of an episode of care including key clinical landmarks. An easily accessed summary overview would be particular helpful for obstetricians managing prenatal care or pediatricians at well child visits. Providing caregivers with a customized consolidated clinical snapshot is also particularly relevant as  comprehensive disease management across multiple visits and providers expands in conditions such as diabetes, heart disease, hypertension, depression and low back pain. As health care is increasingly bundled and care managed across inpatient and outpatient settings by multiple caregivers, an accurate summary of the patient's course is critical to a successful outcome.  

3. Decision support at the point of care

Implementation of best-evidence, clinical practice guidelines in clinical workflows is central to the value-based model of care. By reducing inappropriate variation in care, the expectation is for improved patient outcomes (quality) at reduced cost, i.e., increased value. I've previously described the need for further study of the actual impact of CDS on clinical outcomes and cost.  I've also noted the need to expect deviation from protocols based on clinician judgment and individual patient circumstances, preserving physician creativity and innovation. Cutting edge health IT is crucial to implementing this hybridized personalized evidence-based medicine approach. Streamlining data entry along physician-created workflows with minimally intrusive decision support improves efficiency and restores opportunities for authentic and critical interaction with the patient. When the physician spends less time performing as a data entry clerk and more as an empathetic clinician both caregiver and patient satisfaction improves.  

Caregivers want access to evidence-informed recommendations in the exam room during the visit at decision points in the patient's care. It's inefficient and not realistic for the busy clinician to disrupt the flow of the encounter to search for a guideline in a secondary database. Likewise, it's not acceptable to bombard clinicians with multiple "best practice alerts (BPAs)" or pop-ups during the documentation process. Likened to texting while driving, multiple BPAs lead to "alert fatigue" and are ineffective in significantly changing practice. Re-imagining the EMR with today's technology requires working with clinicians to define clinically important decision support and provide it when needed at the point of care.

Faced with reorganization of U.S. health care driven by reimbursement models emphasizing data-driven value-based care and bundling, physicians need a partner--not an enemy--in health care information technology.  For the benefit of both caregivers and patients, It's time to creatively re-design how clinicians interact with health care IT. 

Get in Touch with Dr. Mazanec 

About Dan Mazanec, MD

Prior to joining Dorsata in 2016, Dan Mazanec, MD was the Associate Director of the Center for Spine Health at the Cleveland Clinic. Board certified in internal medicine and rheumatology, he has been a leader in the development of the emerging specialty of Spine Medicine. A frequent lecturer at international and national meetings, he has authored more than 70 book chapters and papers. He is an active member of the North American Spine Society with a particular focus on the development of evidence-based clinical guidelines as a member of the Clinical Guidelines Committee and the role of non- surgical care as chairman of the Rehabilitation Interventional Medical Spine Committee. Dan led the development of the Cleveland Clinic Spine CarePath which merges evidence-informed clinical management of spine disorders with patient-entered clinical outcome data focusing on optimizing value. He was the clinical lead for technologic enablement of the CarePath in the EMR and the implementation of the Spine Carepath across the entire Cleveland Clinic Health System.