Category: Uncategorized

“If you want a job well done, do it yourself”

I lived most of my life with this simple saying. He further said you should have all the skills to be in control. I endeavored to live up to this and excel at what I did. I strove to excel not only in doing everything myself but even in finding my weaknesses and trying to overcome and excel at them.

Just over two years ago I realized I was wrong. Not my Dad, I was wrong. In my interpretation of the words ‘job well done’.

I thought of ‘Job’ as each task, each activity, and each detail. So wrong I was. I have excelled when it came to Strategy and Processes – seeing the big picture and finding solutions that are most apt. My weakness has been details – micro-managing.

I wanted to improve. I Read books, and took coaching classes. Time management and details management.

It hit me when I turned 50. 3 words = 1 simple word. The words ‘job well done’ meant just one word – Goal. My focus was on individual tasks rather than the Goal or big picture.

What did I do about it?

Once I realized this, I decided to take action. I did two simple things:

1. I hired a Personal Assistant
2. I outsourced simple tasks that I used to do including my own bookkeeping, accounting, etc.

That changed my life in two ways:

1. My quality of life improved. I now have more time for myself and I am happy and stress-free.
2. My revenue has actually increased by 45% in the last two years. This is something that came as a bonus because I am able to focus on and amplify my strengths. (see my previous blog post on ‘amplification of strengths‘)

If you think letting go and outsourcing tasks is expensive, think again. I am a living example of this false thinking.

Dr. Lawrence Gordon, an ENT Surgeon in NY provided a unique perspective on why EHR dissatisfaction pervades among Providers.

Theory of Amplification

Dr. Gordon talks about EHR as a tool that can be used to amplify the intrinsic talent that Doctors possess. It can be likened to the explanation Archimedes gave to the principle of Lever. While Archimedes did not invent the lever, he gave an explanation of the principle involved in his work On the Equilibrium of Planes. The principle of lever was used to design block-and-tackle pulley systems. The goal was to lift objects that would otherwise have been too heavy to move.

In today’s terms, we see increasing use of Robotics in the manufacturing sector that does the ‘heavy lifting’, allowing people to be creative.

In both instances, these are tools that amplify intrinsic talent.

What are you trying to amplify?

Doctors and Clinical Providers want to amplify their experience and empathy. Unfortunately, they seek out EHR to directly amplify these. This is precisely where it breaks down.

The goal must be to use the lever of EHR to create processes and an environment that allows amplification of inherent talent.

To be precise, we must use EHR to:

• Visualize data that allows better clinical decision-making
• Automate health maintenance rules for better patient care and interaction
• Provide focused educational content based on diagnosis and assessment

In other words, strengthen the processes outside of the exam room so that Providers can Amplify their experience and empathy using the data provided by surrounding systems, inside the exam room.

The goal should not be to ‘master’ a tool, but to use tools to help providers function at high efficiency. Efficiency does not mean clicking buttons and a mouse, it means amplifying strengths.

When I was in Dr. Gordon’s clinic on a Monday during his lunch break, it suddenly became obvious why his practice looked calm on his busiest day when he typically saw 45 patients.

We all love bargains. Now we can look for them from the comfort and privacy of our home or office. Comparative websites allow us to do that. Competition makes it good for us (bad for vendors).

We want everything in short steps. A quick way to lose weight, lotteries, an easy and fast way to make money and even looking for systems and tools that can help with our practice such as EHR. Sometimes one of these shortcuts pays off and it reinforces our belief that there is always a shortcut.

The problem is, that these shortcuts don’t always pay off. We spend too much time looking for money-saving shortcuts.

But when it comes to EHR / EMR software, there are no shortcuts. This is one reason why so many providers are looking to switch. They made a decision initially in haste, looking for shortcuts; soon to realize that there is a lot of effort needed by all stakeholders.

By all stakeholders, I mean all members of your staff as well as your vendors. Vendors are really partners in your success. If either stakeholder does not come into this as a partner, pause and question why.

Strive to fix it – internally or externally. Change staff, or change vendor, sometimes both.

I re-read an article in Fast Company that was written 4 years ago to see if it is still relevant given that there is so much emphasis on mHealth software and applications these days. (Here is that article)

This article lists a few iPhone apps that are recommended for Doctors and Providers. Some of these are still around. At that time very few electronic health record systems (EHR systems) were robust enough.

I have seen an evolution of EHR systems that incorporate a lot of functionality that required separate ‘apps’.

With the majority of them now on the Cloud, you can access not just one or two mHealth apps, but the entire system on your mobile device with a browser.

How times have changed?

Kyle wrote a very precise article related to Medicare’s refusal to pay for readmission within 30 days of discharge from a hospital.

He summarizes it well – ‘But this is intrinsically a superficial strategy, not a strategy that addresses the underlying cost problems in healthcare delivery.’

The second problem I see is not addressing the issue from a patient’s perspective. The <30 readmission rule can potentially put patients in harm’s way, just as I have found in my case, it was so difficult to get approval for an MRI when my back hurt.

Reducing costs must be addressed, but not at the expense of patients.

I’m sitting at the Las Vegas McCarran airport returning from a fantastic Healthcare IT Marketing and PR Conference hosted by John Lynn. This is also one of the rare airports that has free wifi.

That’s not what I want to talk about though. I am sitting at the gate waiting for my flight. A young lady sat right next to me. I thought she limped a bit. As soon as she sat down, she plugged in her laptop to charge it, connected to the free wifi, and within 5 minutes, she was on the phone.

‘Hi, is this Dr. Podiatrist? I am looking for an appointment next week. Ok, thank you. This went on for 7 calls. She mentioned on one of the calls that she was looking up her Insurance company’s website for participating podiatrists, and she wanted to see someone close to her office.

Finally, on the 8th call, she did find someone who had an availability.

As each call was made, I could sense her frustration grow and her sighs get louder.

Why is it so difficult to find a doctor and get an appointment? We can book flights, find, review, and book dinner at restaurants without talking to anyone.

Is this the last bastion?

The Number One reason to hate EMR is that it slows down doctors.

The ‘it’ that is being referred to is what happens in the exam room with a patient; the clinical encounter. Doctors are no longer scribbling on paper, they are using computers, and they have to collect data, and click on templates. Worse, they have to type or somehow enter their findings, assessments and plans into the computer.

For some doctors, it is a piece of cake, others hate it with a passion.

EMR has gotten a bad name because of this – SMD (Slow Me Down) Factor I had written earlier about.

Even if all other elements of the Practice Software help improve the office productivity significantly – front-office to back-office workflow, productivity, better collections, efficiency, etc. it doesn’t matter if the doctor is afflicted with SMD Factor.

Do Not Despair – there are choices and options.

There are 6 choices. You will pick the most appropriate choice for you depending on the following factors:

• Technology comfort, savviness, and ability to use computers.
• Number of Patients seen (or you would like to see) per day.
• Relative importance and value of time vs. money.

1. Templates and Keyboard. Standard, out of the box, nothing to add. No additional cost if the system has the templates you need.

• Assumption: You can type reasonably well, you can manipulate templates, and click fast enough to keep pace with your patient volume.
• Cost: No additional cost.

2. Templates and Dictation software like Nuance Dragon. The difference compared to the first option is that you can use the templates reasonably well, but you are not a good typist and you need to enter your findings, plan, and HPI in detail. The use of Dictation software allows you to ‘cut the keyboard’. I recommend this option if you are not a good typist.

• Assumption: You are willing to work with Dragon software for voice recognition. This technology has come a long way. If you tried it a few years ago and found that it did not work well with your accent, try again. A lot has changed, you may be surprised.
• Cost: One-time charge that is approximately $2000 for Dragon Dictation software.

3. Digital Pen and Dictation software. Option 2 was good if you were good with computers and templates in general but not a good typist. If you are generally computer-averse and don’t even like clicking on templates, this is a good option for you.

Digital Pen is a wonderful advanced piece of technology that allows you to use normal paper. When printed with custom paper templates, it takes your markings on paper and maps them to your computer templates as if you are clicking on-screen. The best part is, if well designed they can convert paper to discrete data.

• Assumption: As with the earlier option, you must be willing to use Dragon software for dictation.
• Cost: The cost of preparing custom forms for Digital Pen can vary from $1000 – $2000 per form depending on the complexity of the form. So, if you need 5 custom templates, it can cost up to $10,000. This is generally a one-time fee. The cost of the pen can be up to $500 and perhaps a $60-$70 monthly fee.

If you add total upfront costs when amortized over 3 years, it will be less than $350 per month, but it gives you tremendous peace of mind and productivity gain for yourself.

4. Transcription. Most Doctors are aware of this option and have probably considered this at one time or the other. This option is perhaps the simplest one, but there is now a new twist. The transcriptionist needs to listen to the dictation and not only type a narrative but also work the EMR to select options in the templates for discrete data – physical exam, assessment, etc. In addition, when the provider uses a paper superbill that must be sent to the transcriber to enter in EMR – this expands the role of the traditional transcriptionist.

• Assumption: Expansion of transcriptionist responsibility to be able to work and use EMR.
• Cost: Can vary, but consider $10-$15 per hour.

5. Scribe: The concept of having a scribe do all the work on EMR has been in the news quite a bit and is being widely discussed. There is no doubt that it can completely eliminate the SMD Factor. You must be comfortable with a scribe being present during the encounter with a patient. This is generally not a good practice for certain specialties like Psychiatry, but for others like Pediatrics, Family Practice, or Internal Medicine it may be generally acceptable.

Scribe as an option has two variations: A Remote scribe that can be out of the clinic somewhere else or an in-clinic scribe.

• Assumptions: Willingness on the part of the provider and patient to accept the presence of a scribe during the encounter.
• Cost: Remote scribes can cost an average of $15-$18 per hour, whereas in-clinic Scribes (Medical assistants) can cost anywhere from $25-$30 per hour.

6. Combination: Sometimes a Combination of various options mentioned here can also work.

Conclusion

You need to analyze each option’s Return on Investment, your desired goals, and comfort levels and pick the one that makes the most sense. You should seek an expert’s help to help you analyze your objectives and choose what works for you. There is no single best method when it comes to how you interact with EMR.

Arthur L. Caplan, Ph.D., did a Video Blog on Medscape that has invited almost 250 responses as I am writing this.

Would a Scribe Repair or Destroy the Doctor-Patient Bond?

EMR or EHR has made tremendous strides in bringing workflow efficiency to medical practices and ambulatory clinics. Current EMR Software technology has also partially solved the remote access and data repository problem for patient disease management, but not the data entry obstacle.

Data access and disease management won’t be important if point-of-care data entry is a problem.

EMR and EHR software may not improve efficiency for the doctor if he/she is not a good typist or good with computers and they try to do everything themselves. EMR software has certainly improved workflow and documentation in the service of the healthcare system as a whole. With improper EMR systems clinicians become data entry clerks.

I disagree with Art to some extent. Scribes may work for some types of specialists, as many doctors have noted in their comments.

There are also other methods that can solve the data entry conundrum.

I generally start with evaluating each individual Provider and their clinic to determine their level of comfort with computers, typing speed, speech recognition, comfort with templates, and perhaps a combination thereof.

Usually, I find that the best option is a judicious use of all methods.

• MA/PA/Nurse (you can call them scribes) enter chief complaints, review systems, and even basic HPI, vitals, and refill requests. Before the provider goes into the exam room, the chart is pulled up with lab/pathology/radiology results on the screen.
• Dr. views the note that the MA created before entering the exam room from their own office (like viewing the paper folder before entering the room).
• In the exam room, the Doctor does minimal necessary clicking after spending essential time with the patient one-on-one. The level of ‘clicking’ involves diagnosis, procedures/orders, and medications. After the patient has gone, the Doctor dictates findings (detailed HPI, impression, and plan) with Dragon software or voice dictation for transcription. This should not take more than 2-3 minutes.

This kind of approach results in saving providers time and allows them to go home early. Sounds optimistic? Not necessarily. Involve your vendor or consultant to help you create an efficient workflow for yourself to create a truly rewarding patient engagement without wasting time with computer screens.