Dear Dr. Jayne,
Is our current EHR paradigm dated? Docs practiced for years with paper. Pencil evolved to ink, both inscribed on compressed wood. Housed in manila folders, stickers provided the index and retrieval involved sight-based interpretation based on patient names. Then, we introduced computers. Initially similar to the paper paradigm, full summaries in ANSII or images are stored in a paradigm that still resembles folder-based paper storage. From the images and full ANSII summaries came discrete data points. Ink on paper had now evolved to data capture as unique field based database storage. Over time, these discrete data points will become much more comprehensive.
With all the technical advances where is the industry going? Will the paradigm shift from practicing medicine on discrete data points to something else, and when? Will medicine be able to shift? Is multimedia the next frontier? Just like the initial paper to electronic chart paradigm shift, when will computer science convert images and video to discrete data points? We all know the value of discrete data.
Fan of Dr. Jayne from the Deep South
Dear Southern Fan,
You pose some interesting questions. Given the fact that physician recordkeeping didn’t change much for hundreds of years, the relative pace of records evolution at present is staggering. We’re already becoming fairly adept at converting spoken language into discrete data, allowing physicians to document patients’ stories not only with codified data points, but with the rich narrative that frames individual patient circumstances and situations.
In my opinion, the biggest barrier to the kind of documentation that can be envisioned is unfortunately the proverbial hand that feeds us. The regulations, policies, and requirements of CMS are still stuck in the paper paradigm. And as we all know, as CMS goes, so go the rest of the payers. Despite federal mandates to take the technology forward — such as HIPAA and HITECH — healthcare providers are still being scored based on documentation standards that have not evolved in more than a decade.
Physicians can’t get “bullet point” credit for documenting a cancerous skin lesion with a photograph. They say a picture is worth a thousand words, but in an audit, a picture is worth nothing.
I remember sitting in medical school watching a video of a child with whooping cough. No written description could ever take the place of that. When you see and hear that kind of pathology, it’s etched in your brain forever. Nevertheless, embedding a video clip of a patient isn’t worth anything, either. I can look at a photograph of a diabetic foot and tell you a lot more about a patient’s illness and status than I can glean from a multi-page nonsense note generated from a poorly-implemented EHR.
I once heard someone say that our thinking is constrained by the technology of today. I don’t think that’s the entire problem; our vision is also constrained. And it’s not the technology that locks us in, but also the auditing and payment paradigm that hobbles us.
I was initially hopeful that the rise of Accountable Care Organizations with their risk-sharing and outcomes orientation would help us move to a more modern way of thinking and documenting. It doesn’t look like the fact that providers and payers are sharing risk is going to move us away from the incessant and costly paradigm of documentation for documentation’s sake.
The promise of telemedicine and other technology ventures such as real-time electronic patient communication was exciting. However, lack of payment and increased regulatory burden continue to keep it from realizing its potential. I’d like to think the future’s so bright we’ll have to wear shades, but I’m not sure CMS agrees.