American College of Physicians: Internal Medicine — Doctors for Adults ®

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Wednesday, August 21, 2013

Real meaningful use

It has been nearly 6 months since I started my new practice, since I took the jump (or, more accurately, was pushed off the ledge) into a brave new world. It seems very distant, like I should get Shirley MacLaine or Gwyneth Paltrow to help me channel my old sad self. It is tempting.

I have a vague recollection, a memory shrouded in mist, where I pondered what seemed like a radical question: What would a health record look like if my only concern was patient care? This was a radical question because in my previous life I was an electronic health record aficionado. I was good at EMR, which meant that I was really good at finding work-arounds:

• How can I work around the requirements for bloated documents and produce records that are actually useful? The goal of records in that previous life was to justify billing, not for patient care.

• How can I work around the financial necessity to keep my schedule unreasonably full and keep my visits unreasonably short and still give good care?

• How can I work around the fact that I am paid better when people are sick and still try to keep them healthy?

• How can I work around the increased amount of my time devoted to qualifying for “meaningful use” and still give care that is meaningful?

Computers were all about automating the drudgery, organizing the chaos, and carving out a sliver of time so I could spend the extra minutes needed to give the care I wanted to give. I was using them to give good care despite the real nature of the medical record: a vehicle for billing.

But that was my past life. Now I no longer have to worry about a Medicare audit (and the looming threat of an accusation of “fraud” for simply not obeying the impossible documentation rules). I no longer have to keep my office full and my patients sick enough to pay the bills. I am actually rewarded for handing problems early, for communicating well, and for keeping patients healthy and happy, as it keeps them paying the monthly subscription fee.

Ironically, in asking the question, what would a health record look like if my only concern was patient care, I was really asking the question: what does “meaningful use” of the record really look like? Now this question is no longer a hypothetical; it is real. My rejection of EMR systems that catered to my previous needs and my quest to build one that fits my current needs have given me the chance to work very hard at answering that question. The success of my practice, and the success of other practices like mine, will depend on our ability to answer that question. I am now in a system that actually values communication, prevention, and organization, so I no longer need computers for work-arounds; I need computers to help me reach those goals.

As I’ve spent an enormous amount of time and energy (a.k.a. obsession) on my own system, I have come up with unexpected opportunities:

1. Abandon the artificial centrality of the office visit.

The care I gave in my former life was held hostage to the office visit. This is not only (as I have mentioned before) the unit of commerce, but the unit of documentation. Even in my new practice, where I am no longer loathe to give time and information outside of the office visit, I still am drawn to this unit of documentation. Why? Isn’t in-office care merely one of many communication options? Isn’t it part of a continuum of communication happening over time? Why should I separate the phone call earlier in the day from the visit that phone call prompted? Why should I wait until they are in the office before getting a history?

An example came a few weeks ago when a patient injured her finger. She has close contact with a dentist, who offered to get an X-ray of the hand. I got a secure message with a jpg attachment of that X-ray, revealing a fractured bone at the end of the finger. I messaged her back, telling her what to do about it, including my nurse on the message, asking if we had purchased splints when we started the practice. We hadn’t, and so Jamie ordered them, notifying the patient when they arrived. The patient spent a total of 5 minutes in my office, but the care extended over several days.

This scenario has repeated itself in other forms, including: diaper rashes that don’t heal (more pictures), intermittent abdominal pain, new-onset diabetes treatment, and post-lumbar puncture headaches. Attending to these problems as they happen (instead of requiring office visits) is far better for both patients and me. My availability to help patients in this circumstance lets me handle problems while keeping my office empty, while my empty office enables me to have the time to answer these questions (without the previous angst over lost revenue).

So how do I document this? The records of my former life didn’t consider such questions, but my new freedom brings this issue front and center.

2. Embrace Simplicity and Organization.

When dealing with such problems, the focus is not only on communication, but informed communication. Since I am not forced to gather all of the facts at an office visit (a truly impossible task for both doctors and patients), I need to have a better way of keeping track of things. I have to have a record that immediately tells me what I need to know about the person with whom I am interacting. The best decisions are made with the clearest picture of the situation, and I need a record that gives me that picture as efficiently as possible.

This is a far cry from my former life, where I was forced to include massive amounts of E/M vomit in every note to justify billing. The facts were hidden in the medical record, not revealed by it. What was the penalty for not having all the information I needed or for the bad decisions that were the result? Patients stayed sick, came back to the office, and I got paid more.

So, I have been forced to find new ways of organizing information. When I look at a person’s medical condition or a specific symptom, I want to have access to:

1. All medications related to it.

2. All encounters where it was addressed.

3. All associated testing, procedures, surgeries, and hospitalizations.

4. The opinions and contributions of other doctors on the issue.

5. A clear idea of its impact on the patient.

I want this information with as little work as possible so my communication can be as efficient and effective as possible. It’s been a tough task, but I think I’ve found a way to do this without demanding extra work.

3. Give that record to the patient.

I am not the only one who needs good information; the patient is an equal participant in these conversations, and the one with the most to gain from good decisions. The only solution I can see is to put this information where it belongs: in the hands of the patient.

If I had embraced this idea fully in my previous life, I would have been faced with a problem: the medical records sucked. The useful information that happened to be present in the record was buried in piles of coding compliance refuse, obscured by reams of superfluous data. Our records were better than most, and yet sharing them would reveal to our patients how little time was spent keeping them organized and accurate. We simply had more important things to do: things that paid the bills.

Creating a truly meaningful and useful record has not simply been something I’ve done for myself; my ultimate goal is to not only give them to the patient, but to invite them to help me in the never-ending task of keeping them organized and updated. My job will be to curate that information, as I better understand which parts of the information should be emphasized, and which should be available when needed.

I’ve got more points to make, but will let that go to another post. The point I want to make clear is this: The radical change in my payment model has forced an equally radical change in the systems that support that model. I can’t put new wine in old wineskins. The medical record of my past life was built to help with the problems inherent in that sad existence, and they served to amplify the sadness of that existence. Now living in a much happier, patient-centered world, I can build something that will increase that goodness and happiness.

Sorry Shirley and Gwyneth. I think I will stay where I am.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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