Blog by David Goldberg
At the end of last year, Dr Atul Gawande wrote an article in the Medical Journal ‘Annals of Medicine’ which caused sufficiently interest to be reprinted in the New Yorker magazine. The link to the whole article is here:
Essentially this is a thought piece about the benefits and is advantages of digitisation, but very much looking at the changes that are in process from a user perspective – both practitioner and patient/citizen.
Our retired colleague and founder member, David Goldberg provides below a series of reflections on the piece, as bullet points, rather than formal text.
Thoughts about Atul Gawande’s New Yorker article David Goldberg
Electronic Medical Records:
- Benefits of an integrated Electronic Medical Record:
- Documentation of all of the patient’s information, events, etc. in one place
- Patient access to their information (via portal)
- Reduction of paper results and records
- Speed of getting results of tests to provider
- Presumed ability to utilize patients records as source for population based research
- Asynchronous way for providers, patients and others to communicate
- Too much information – without clear priorities
- Too many hands can make changes
- Provider adaptation to use of pre-written (stored) results that lengthen communication without adding insight or understanding
- Increased entry errors as a result of so many hands making entries
- Very slow speed of software changes due to impact on others, priorities set by software developers rather than users
- Multiple systems across the provider landscape that do not integrate easily
- Still too many paper results needing to be integrated via scanning
What do Patients want/need from their primary care providers?
- Compassion and awareness of the context in which patients live
- A good listener (to reported symptoms, and a miscellany for information the patient has gleaned from friends, the Internet, TV commercials etc.)
- Someone who can track conditions/trends over time
- Availability/Efficiency (appointments quickly, on-time)
- Friendliness and professionalism of staff
- Cleanliness of surroundings
- Sensitivity and awareness of the costs of care options
- Understanding (problems/issues explained in simple language with clear idea of the likely outcomes of tests, treatments etc.)
- Timely results quickly communicated particularly when the results are potentially serious (e.g. biopsy results)
- Privacy and Security of information
- Reminders (preventive actions such as vaccinations, need for routine checks etc.)
- A provider who knows how to navigate and can advocate for the patient in an increasingly complex medical system
What do Primary Care Providers want from Electronic Medical Records?
- Single place to store patient information
- Easy access to important, timely and relevant information
- Seamless connection to the rest of the medical community
- Easy ability to see trends in individual patients
- Ability to see trends in their practice (research tool to assess their workload) for the population they serve)
- Elimination of myriad bits of paper
- Ability to asynchronously communicate with patients, colleagues and other components of the healthcare system (insurance, hospitals, consultants, pharmacies, nursing homes, home health etc.)
- Added efficiency during the work day so as to have more face-to-face time with patients
- Reduced time on the telephone with other actors in the system
- Back-up of data
- Security of information
Some realities of primary care delivery in America:
- Serves as the wide open end of access to a health system where much of the interaction is educational, reassurance, capturing relevant data.
- Productivity/financial issues (their income is based on it, covering the high costs of overhead, meeting the growing demands of a population who demands quick access, efficient care and expert advice). This alone creates problems when the average time available to a primary care provider is 10-15 minutes with each patient – which simply may not be enough time to address current problems and adequately listen and respond to patient’s needs)
- Facing the reality that in many/most primary care practices the leading diagnosis of your patient population is “depression” (a proxy often for an array of mental illness)
- The soaring volume of data from myriad sources (paper results, letters have not gone away so electronic medical records must accommodate input of paper information e.g. scanning)
- The legal liability issues around mistakes, not following community standards of care, and missing something. The EMR may be escalating the risk of missing important information as it grows in volume and complexity.
- In many cases the need to manage a small but complex business with money, staff, facilities etc. issues
- The American medical system values procedures over care and problem identification/solving
- The EMR is becoming a repository of a vast amount of information with little insight/wisdom. As the volume grows so does the challenge of getting what you need from it quickly.
- The EMR has multiple users with different priorities (e.g. insurance filing, coding, legal etc.)
- The number of primary care providers is inadequate to care for a growing and aging population and primary care residency programs were finding it difficult to fill classes.
What can be done to improve the current EMR situation?
- Move to a single national EMR or insist on compatibility across platforms
- Archive all information but highlight/push relevant new information to a clear priority list
- Train support staff to navigate and distil emails, voicemails, instant messages and new information and only involve the primary care provider in critical messages and findings
- Develop artificial intelligent software to seek patterns that can be presented to providers
- Work with practicing providers to eliminate as much “noise” and unnecessary keystrokes from existing EMR systems
- Employ more PAs and FNPs to meet the growing primary care need and to deal with less complex patients and conditions