Over the past eight months, I’ve started back in part-time internal medicine practice in Columbia, MD, doing mostly urgent care visits in coverage for other internists and family physicians in a private practice setting. I chose this opportunity because of difficulty finding a routine in Washington, DC (near my office) that could accommodate my erratic schedule. I work evening hours and occasional Saturdays. This has been quite a bit of fun. I am enjoying seeing patients again after not doing so for almost two years and, while I am not managing my own panel of patients (yet), the collaboration and shared responsibility with the other physicians, nurse practitioners, and physician assistants in the practice has been very rewarding.
Going back into practice after such a period of time does have its challenges. Regaining confidence in evaluation and management has taken some time and is an ongoing process. Rebooting long-standing routines I developed for history-taking and physical exams took some time. I’m more dependent on my peripheral brain (apps on my “smart phone” and bookmarked resources on the laptop) than I’d like to be — but that’s improving, and in fact, I’m not sure how I got along without such ready access to this information in the past. Unfortunately, such guidance is not readily accessible through the EHR in use — but hopefully that will change with the Infobutton standard and upgrades over time.
I was happy to discover that talking to patients and families seeking help came back relatively easily and, though my typical evening hours go from 5 pm to 8 pm after a long day at my day job, I’m energized by these interactions and look forward to remotely tracking patients I’ve seen to stay apprised of their treatment and follow-up — a benefit of EHRs that was not possible during the days of paper-based records.
Interacting with and using the certified EHR has been… interesting. Due to the practice setting and types of patients I see, I haven’t used several of the longitudinal care documentation processes (e.g. preventative screening reminders, flow sheets, graphing, routine immunizations) other than to check items relevant to the issue/concerns of the visit. My use of the EHR has been predominantly to generate progress notes, update medication lists/allergies/problem lists, use e-prescribing, order/retrieve laboratory tests/procedures, and to initiate referrals. Even with that limited set of EHR interactions, I could fill pages and pages with narrative describing the challenges of documentation, lab test and procedure ordering, viewing electrocardiograms, finding formatted notes and referral templates, limitations on simultaneous viewing of charts, internal email limitations… and so on. It would be very, very, very easy to become frustrated and demoralized. As AmericanEHR documented in our HIMSS 2013 report, satisfaction with EHRs has dropped over the past couple of years.
It was while these concerns were running through my brain that I read Dr. Peter Basch’s blog post on Clinical Innovation & Technology last week entitled, “Perspectives: It’s not either-or for patients and EHRs.” Peter describes an encounter with a patient that took place after his computer had been shut down and staff had gone home. While waiting for the computer to reboot, he completed the essential elements of the visit on paper including, believe it or not, a handwritten prescription. As he put it, it was a “100% eye contact, 0% EHR” visit. All good — right? But then the EHR popped open and Dr. Basch discovered things that his history taking did not reveal. A potential drug interaction, missed screening tests, an elevated glycohemoglobin, and so on. Peter demonstrates that a few extra minutes spent caring for this person based on the additional information provided by the EHR resulted in better care. While it might lead to a higher E&M code, overall, the cost would be less than having the patient come back for each issue on separate visits — something to consider when analysts suggest that EHRs lead to “upcoding.”
Peter concludes with the following statement:
Our shared goal should be to make the time “in front of the screen” of the highest value for doctor and patient; and not to consider screen time as something to avoid.
What do you think of Dr. Basch’s observations and conclusions? Do you have any related stories?
AmericanEHR, its partnering medical professional societies, and other health IT organizations, are all working towards driving improvements in EHR design and implementation by collecting information from those of you using certified EHR technology and then reflecting the findings through reports and tool sets on the site. We welcome your stories and comments, and welcome proposals for guest blog posts. Your anecdotes provide punctuation to the data and draw attention to the positive and negative aspects of health IT.