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Archive for May, 2005

A work in progress … lessons learned by visiting many offices

Working with physicians across the country of whom many seem paralized in getting their practices digital. The following points are the beginnings of an outline for an article on a new paradigm in medical office practice and is based on lessons learned by visiting many clinics over the last 10 years:

  1. Get digital with an ELectronic Medical Record (EMR). Any EMR is better than no EMR.
  2. Technical infrastructure is the blood stream of any EMR. Failure to invest in infrastructure will cripple any system. Attempt to network every device within the office (scales, endoscopes, automated vital-sign devices, even otoscopes, ophthalmoscopes, dermatoscopes, CLIA waved laboratory equipment and any other device used to probe, measure or view any part of a patient’s anatomy). The goals should be to:
    1. Eliminate human data entry (the largest source of error) and
    2. Let the patient see what the clinician sees
  3. Work together with as many physicians who share the care of patients. Can never leverage economies of scale if each practice insists on using their own customized EMR solution. Furthermore sharing an EMR (especially the underlying clinical repository) eliminates many of the redundant steps required to push paper from one disconnected office to another. Referral letters, among other things, disappear with a shared repository.
  4. If at all possible use the same system and repository the hospital to which most of your patients are admitted.
  5. Learn to think in terms of a "disease" or "patient watershed." All physicians and health care providers (including allied, alternative and complimentary providers) should be sharing a single clinical repository. Only then will much of the inefficiencies in medical decision making disappear.
  6. Interfaces, though costly, are extremely valuable and offices should budget 30% of the operational cost to maintaining and expanding them. The goal of an office should be to not have to do any de-novo data entry on the next new patient.
  7. Do not implement any EMR after the current-state. Instead change the practice to exploit the future-state. Any irritation today should be something that’s designed out of the system.
  8. Become customer focused and attempt to learn to take care of each patient’s concerns at the 1st point of contact. This means that physicians should be able to register, schedule, check-in and check-out patients whether they are on call, in the exam room or whenever they come into contact with patients.
  9. Implement systems that let the patient view the entire record. This way the practice will be assured that nearly 100% of the charts will be audited. Charts that are audited are usually more complete, accurate and useful than those that are not. Not only that, patients that can see the information the physician sees will be better informed and more satisfied.

    Am coming to the conclusion we’ll never really be able to exploit our EMRs until each and every patient is a user of the system. We should purchase them that way rather than trying to minimize the number of users.

  10. Learn to take more time with each patient and see patients that require physician’s time. There are many patients that do not need to see a physician but only require the nurturing care of nurses or therapists. Let everyone in the office be involved in the care of patients personally. The practice will be able to meet the needs of their patients better this way.
  11. Never trust your own fund-of-knowledge. The half-life of most knowledge is only 60 months. Learn to access the latest knowledge before making any but the most trivial of decisions. This ultimately saves time and gains the patient’s trust when this is done in front of the patient.
  12. Learn to use the computer well in front of patients. This isn’t easy but isn’t as hard as becoming an expert with the stethoscope.
  13. Don’t blame any system for not extracting a quick return on investment. Doing so is tantamount to blaming a car for not getting across town as quick as you wanted. There’s less variability from one EMR vendor to another than there is within each vendor’s EMR. Most of the factors that matter are external to the EMR, just like getting across town depends more on traffic lights, road construction, speed limits and other drivers than it does on the make of one’s vehicle. It is ultimately up to the user to make the application hum. I’ve seen good physicians do wonders out of the crudest of systems and I’ve seem physicians who can’t make the best systems work at all. The correlation coefficient of a given vendor to success is almost zero.
  14. Learn to treat a patient population rather than react to the next sick patient. Practices should mine their own data to help their patient population avoid coming to the clinic after they become ill.
  15. Am conviinced that order entry systems are a revenue stream for any health care institution including offices. They should be opened up to their patient population.

So much for these begining pearls. Am putting them in this blog so they may be easily accessed anywhere.