Friday, September 17, 2010

Physicians vs. Health IT: The EMR Culture War

The recent financial incentives offered by the government (HITECH) for EMR implementation are somewhat helpful but are also misleading.  Most fail to recognize that the biggest obstacles to EMR implementation are not financial, but are cultural.  EMR adoption will require cooperation between two disparate cultures:  the Health IT (HIT) culture and the medical culture.  One needs only to read a few of the EMR debates in any health care blog to discover that these two cultures view the health care system differently.  Until the differences are reconciled, EMR implementation will continue to struggle despite the HITECH incentives.

Buoyed by its success digitizing other parts of the economy, the HIT industry sees in health care an untamed wilderness of inefficient workflows and slow, outdated data exchange.  HIT folks envision a world where standardized workflows and rapid data movement ensure, for example, that a patient never has to wait 30 minutes in an exam room for test results and where day-to-day management of chronic diseases can be done remotely.  An IT revolution in medicine would bring lower costs, better efficiency and improved care.

But there is a dark side to the HIT perspective. After successfully bringing so many other parts of our economy into the information age, some believe they have learned all they need to know to do the same for health care.  The benefits are so clear and so obvious that anyone who would oppose EMR must be either clueless or just “protecting their turf.” I have heard HIT consultants brag about walking out on their physician the minute they saw a paper prescription pad.  They mistakenly believe that health care is no different than banking or grocery stores – that there is nothing else to health care besides documentation, workflow and data exchange.

The medical culture sees it differently.  To us health care is all about the doctor-patient relationship.  In the physician’s world workflows and data exist only to support and execute the decisions patients and doctors make together regarding care.  The art and science of medicine defy, to some degree, traditional software structure and data capture techniques. Our decisions may depend as much upon the look on a patient’s face as on any objective data.  That is how it should be.  The type of personality who is attracted to this kind of work is interpersonal, not technical. We got into medicine to interact with people, not machines.

The doctor-patient relationship gets attacked from all sides. Since the doctor-patient relationship drives one-sixth of our economy that comes as no surprise. The government just passed a huge piece of legislation that will have profound effects on the doctor-patient relationship.  Pharmaceutical companies tell us we need to use their latest drug.  Device manufacturers push the next great Magic Wand for performing a tonsillectomy, sinus surgery or other operation.  Consultants tell us to run our practice like a business.   When we make sound business decisions, we are accused of abandoning our moral obligation to medicine.  To us the folks trying to sell us EMR are no different.  They are just another group that thinks they know how to do our job better than we do.

But the medical point of view has its dark side as well.  We act as if the doctor-patient relationship is so sacred as to be perfect and infallible, privileged from the need to evolve and improve, immune to the economic and performance pressures lurking just outside the exam room door.  If the treatment we prescribe is not the most cost effective choice, let the system deal with it.  If our paper prescription is illegible or non-formulary, that’s the pharmacist’s problem.  If EMR is too inconvenient because of the learning curve, then it doesn’t matter how much more efficiently the system would run with EMR in place.

Bringing information technology to health care will be slow and painful until these 2 points of view are reconciled.  The first step is to realize that both doctors and Health IT are right – and they are both wrong.  Both sides need an attitude adjustment.

Health IT must acknowledge that the doctor-patient relationship is a major part of the health care machine.  Workflows and data are the means, not the end.  Nothing like the doctor-patient relationship exists anywhere else, so the experience gained bringing IT to other parts of the economy is not enough to write good software for physicians.  Little wonder that doctors find EMR software “clunky”, inefficient and difficult to use.   As one physician responding to a survey stated, “in order to contain the subtleties of the medical thought process, these systems have to be complex, flexible, and very nimble.”  Health IT needs to invest time and effort developing a greater understanding of how doctors and patients interact and make decisions.  Only then will the software get better.

The medical culture must understand that while the doctor-patient relationship is unique and special, it is not entitled to be rigid and inflexible.  Over the past several decades the way we do our job has evolved; the evolution must continue.  The doctor-patient relationship is not perfect.  The shortcomings we impose on the rest of the system play a part in the inefficiency and the waste.

Remember when managed care came along 20 years ago?  We dug our heels in and fought against it.  We declared our methods and our high price tag to be above criticism.  So the rest of the health care system created managed care without us.   We are still living with the consequences.

With the impending IT revolution in health care we face a similar choice. If we refuse to accept change, the result will be the same as it was 20 years ago.  If we want a better result this time we must take a leading role.  We must voluntarily leave our comfort zone and bring EMR to the practice of medicine.

Can both cultures admit their shortcomings and meet in the middle?

Monday, September 6, 2010

The ROI of EMR Explained

Some of the toughest obstacles to EMR are the “Physician Doubters.”  These people say, “My charts are going to be on a computer.  So what?  All I know for sure is that it will take longer for me to finish my charts every day and we will have another component in fixed overhead.  Why this is a good idea?” 

The concerns are valid.  When my practice chose to get EMR 6 years ago we made a decision of faith and vision, not from an ROI analysis.  But for most practices, faith and vision are not good enough.  We need a return on investment (ROI) rationale that justifies EMR adoption to the Doubters.  The IT experts talk in vague terms about workflow and re-designing your practice to take advantage of EMR, but these arguments are not concrete or specific enough.  Yet after 5 years of EMR no one in our group has ever suggested that our EMR investment was unwise.  I am convinced the ROI argument exists.  My next few posts will attempt to make the case.

Let’s start with an unusual example.  Your car needs new tires.  You live in a beautiful rural area but there is only one car shop, staffed by a single mechanic.  He is glad to put on new tires but the job will take all day.

Why so long?  How many steps does it take to put on new tires?
1.     Remove the first wheel from the car
2.     Take the old tire off the wheel
3.     Put the new tire on
4.     Balance the wheel
5.     Put the wheel back on
6.     Repeat the above with other 3 wheels, one at a time.

Any interruptions such as other cars needing work, a phone call, emergency, etc. will make the job take longer because these events interrupt the work on your car.  Our solo auto mechanic must operate by sequential processing – defined as one operation at a time.

Now consider the other extreme.  You are an Indy racecar driver going 180 miles per hour around the track.  You need new tires fast.  You pull into the pits and the pit crew changes all 4 tires at the same time.  You also get mechanical adjustments, a full tank of gas, and the windshield cleaned.  A pit stop that takes more than 8 seconds is considered a failure.   This is parallel processing – defined as multiple operations taking place simultaneously.  Thanks to parallel processing the Indy pit crew can do in 6 1/2 seconds what takes the solo mechanic all day.

Now go to the doctor’s office.  The physician sees a patient with a suspicious nodule in his thyroid gland that needs surgery.  How many steps does it take to get that patient to the operating room?
1.     Create a chart note that supports the need for surgery
2.     Schedule the operation with the surgical facility
3.     Preoperative labs, imaging, EKG
4.     Specialist clearance (i.e., cardiology)
5.     Precertification with insurance
6.     Generate and complete documents
a.     Surgical consent
b.     History and Physical
c.      Preop and Postop orders
7.     Communication with the referring physician
8.     Handle the unexpected – patient calls with questions, abnormal lab values, scheduling conflicts, etc

How does the paper chart office handle these tasks?  In all but the smallest practices these tasks are each handled by different individuals.  Every step requires access to the paper chart, which can only be in one place at a time.  The chart won’t be available to anyone for at least 24 hours until the transcription comes back and is filed.  The paper chart office must therefore accept the slowness and inefficiency of sequential processing.  Workflow is defined by stacks of paper charts – stacks waiting for transcription, stacks waiting for labs, waiting for scheduling, etc.  And if the patient scheduled for surgery calls with a question…what stack is the chart in?  Will the chart find its way back to the right stack after the phone call is handled?  Everyone competes with each other for access to the chart.  Not only is the process slow and inefficient, it carries a high risk of workflow failure.

How is the same process handled in a doctor’s office that has EMR?  With the power of parallel processing:
1.     The chart note, including the diagnosis codes, is immediately available to support preoperative workflow. 
2.     The chart note is paperless faxed to the referring physician the same day, sometimes before the patient leaves the office.
3.     The staff is immediately notified of the new workflow via the EMR system
4.     Consent, H & P, and orders are all generated with a single button click
5.     All workflows are performed simultaneously, greatly improving speed and efficiency and reducing the risk of a workflow failure.

With parallel processing there are no stacks of charts and no competition among staff for access to the chart.  Copying and faxing charts within the practice is eliminated.  The chart is everywhere, all at once.  Any phone call regarding a patient is easily handled without having to search for a paper chart and without the risk of killing a workflow because the chart was not put back in the right stack.

So where is the ROI?  The same work gets done with fewer people, fewer resources and less space.  These initial benefits happen without having to “re-engineer the practice” or change anything else about how things get done.  After electronic documenting becomes second nature it will be time to employ the concepts of remote access, computerized provider order entry, workflow design / automation and  “e-patient” functions like secure e-mail and patient portals to really get things cooking.  I will cover those in detail in a future post.

Thanks again for reading and for your thoughtful comments.  The response so far has been very strong, far better than I had hoped.