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Archive for the ‘Health and wellness’ Category

Disease watershed

Most providers of care share patients within a disease watershed. This is a geographical area where people have a high probability of contact, share similar environs and where a critical mass of people spend the bulk of their lives.

Within any of these watersheds there usually are a variety of individuals who provide some type of medical care (physicians, specialists, podiatrists, chriopractics, alternative care, cosmeticians and a host of other people who in some way or another meet the populations’ health care needs). No one person provides all of the care for any one person. Many of these people share information, often at the bequest of the person seeking care. This sharing of information is time consuming, expensive and often trails the need at the time.

It is my contention that within these disease watersheds any person who’s licensed to provide any form of care should share a clinical repository in order to maximize their ability to provide the care they need.

Electronic medical record systems will eventually evolve into larger regional systems that will correlate with the local disease watershed. When they do the population living within those areas will see their diseases managed optimally. Then, and perhaps only then, will we begin to be able to tackle the health care needs that exist and improve the population’s health.

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.

So it begins with transparency

During my residency at an academic medical institution back in the late 80’s we began using e-mail to communicate with many patients who were also employees. We still had paper charts and frequently printed out and place in the paper chart the e-mail exchanges so they could become part of the permanent record. I began asking the patients to look through the charts and sign their contributions. Funny thing happened; they began finding documents of other patients misfiled in their own charts!

It didn’t take too long before a few other physicians were doing the same thing. We started noticing the notes of other physician contributors to these charts were much more concise, clear and the hand-writing improved.


Could it be because everyone who contributed to those charts knew those charts would be audited by the people who cared most, the patients?

Later on when I had the chance to use an Electronic Medical Record that enabled any user to see who else had looked at the chart I began sharing this feature with patients. They immediately liked this and would spend some time looking through the list. When asked they were not too concerned about all of the people they didn’t know who accessed the chart but were angry and disappointed the physician whom they saw previously had not bothered to access the chart! When these physicians were later confronted they suddenly had a change of heart and began to use the Electronic Medical Record.

Don’t have any evidence other than these anecdotal recollections but I suspect that we could go a long way towards improving the quality of healthcare if we turned the medical record, whether electronic or not, on its head and thought of the patient as the primary owner/user of the record and physicians as guest contributors. We would assure 100% auditing and a lot more care would be taken to make sure the right things were documented and possibly the right care provided.

In short, I believe the solution to many quality issues in medicine and business can be achieved through greater transparency. I’m pretty sure that if all the shareholders had access to all of the company documents, meeting minutes and policies there would never be an Enron or similar disasters.