My patients here in rural Maine often ask with a sense of awe and wonder how I possibly keep up with the brisk pace of change in medicine. It’s a good question. When I think of substantive change, I think of major shifts in care and outcomes. Those game changers happen far less often than my patients think – but when they do occur, the impact is profound. That kind of big change is upon us right now and it is about the way we can handle and navigate our way with information.
Patients think we are all rocking to a rapidly beating pulse of discovery but in reality medicine and doctors are fundamentally conservative, even resistant to change at times. Having an effective EHR for our family practice has been like replacing candlelight with electric bulbs but the number of colleagues I meet who are excited or enamored with their electronic health record is small indeed. And most are grumpy.
Witness Milt Freudenheim’s October 8 article in The New York Times, “The Ups and Downs of Electronic Medical Records” in which he reprises the complaints we all hear in hallways: “electronic systems are clunky and time consuming”… “difficult to set up”… “fit only parts of what doctors do.”
From Index Cards to POMR
Maybe I am excited because I’ve practiced long enough, 30 years, to remember the last information revolution, known as the Problem-Oriented Medical Record (POMR). For most doctors today, the POMR is like the air you breathe but I grew up in the days of narrative charts, when the most basic information was buried. Aside from the date and maybe the patient’s name, nothing was particularly clear. It worked very well for the solo practitioner who only needed vague reminders and prompts to recall a lifetime of health history but not so well outside that doctor’s walls.
My late father-in-law was a general practitioner in a tiny Adirondack town, and each patient’s entire history was well summarized on the thumb drive of the day – the index card. One card could contain a lifetime of the basic medicine practiced in the ‘40s and ‘50s. A typical office visit might be summarized like this one: October 25, 1948 abdominal pain – chardonna. Chardonna was charcoal + belladonna, a very popular and effective GI nostrum.
But that same narrative, chronological approach was a horror show in the hospital or to an outsider who could learn little or nothing of the medical facts, let alone the logical thread.
Finding an EHR and its Meaningful Use
Our private practice turned on its (EHR) lights more than two years ago. At the time we had been flagging financially and otherwise. I tried to play catch-up with what I thought what was important in patient care, but felt fogged and defeated by the clutter of our paper charts. What drugs is the patient really on and where can I find that dose? Hospitalizations, mammograms, that chemistry profile? If I was lucky, retracing the wandering trails of prior encounters might lead me to the labs or the drug dosages. If unlucky, I would end up rummaging through stacks of files in the front office.
Fast-forward to today. Now we are a rejuvenated practice, active and engaged in Maine’s Patient-Centered Medical Home pilot, meeting all kinds of outcomes criteria, considered by peers to be a model, and taking care of a very happy group of patients. I might add that this practice – small, free-standing and private – was the first primary care practice in Maine to reach Stage 1 Meaningful Use attestation.
All of this speaks to what can happen with the right EHR. The choice was not obvious at the outset when I stumbled around looking at the major vendors in the field, plus one small start-up, athenahealth. Consultants warned us away from any but the established major players but an athenahealth whitepaper on the design of electronic health records systems suggested to me that the company’s leadership, especially Jonathan Bush, knew where I spent my day.
The other key advice was hearing Dan Mingle, a family physician who is Ambulatory EMR Project Director of Maine General Medical Center, tell a tech conference audience to get an EHR not to fit today’s practice but rather the practice you hope to have in 10 years. And for us the answer was athenahealth.
Seeing Patients, the Forest and the Trees
Now, two years after implementing athenaClinicals and athenaCollector, I could not be happier. We know how and where to organize clinical strategies to handle chronic disease with the focus and the attention to detail that is critical. I can see both forest and trees. Our staff now sees the big picture too and is excited to see the results of their efforts on a broader scale. It is as important as ever to make each patient feel cared for, but the larger picture of community health is there too.
Still, the elephant in the medical office is cost. Cost remains the denominator in every health care equation. I don’t how we will solve the problems of quality and cost but we all have skin in this game. Maybe it will come down to nickel, diming and rationing, but more likely we will address cost by figuring out what really works, what the best ways are of taking care of people and not thinking so directly about cost.
Consider another New York Times article, by Bill Keller, “How to Die” published on Oct. 7. It was about his British father-in-law’s experience of terminal care in the United Kingdom. That care is routinely much more palliative and humane than typical end-of-life care here in the US. Over there on a family visit, Keller asked an attending whether this palliative approach comes from a desire for economy. “I don’t think we would dare,” responds Sir Thomas Hughes-Hallett in the article. “There was some very nasty press here in this country this year about the Pathway (a hospice oriented program), saying it was a way of killing people quickly to free up hospital beds. The moment you go into that argument, you might threaten the whole program.”
In America, nothing happens without a cost-benefit analysis. But the case for a kinder way of death can stand on a more neutral, less disturbing foundation.
“There are lots of reasons to believe you could save money,” says Dr. Ezekiel Emanuel, a bioethicist and writer for The New York Times, in the same article. “I just think we can’t do it for the reason of saving money.”
I wonder if we perhaps we might figure out cost containment through this sort of third way. I believe that finding the ways that really work will get us there. And without question, the right EHR is the key.
Dr. Steve Bien is an athenahealth client. He runs Wilson Stream Family Practice in Farmington, Maine.