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Curbside Consult with Dr. Jayne 11/14/11

November 14, 2011 Dr. Jayne 4 Comments


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.

Dr. Jayne


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Currently there are "4 comments" on this Article:

  1. Amen! The electronic record presents the opportunity for a paradigm shift. Constraining it to a paper-based paradigm bound by regulatory oversight is precisely the major obstacle to a better record. It is akin to spending all your effort on how to better handle check images when the world is moving to a debit transaction off a cell phone. For example, the dynamic electronic world lets us document a patient snapshot with each element 100 layers deep instead of re-documenting the entire patient note 100 times with only a few elements changed each time. But we are regulated (and paid) to mimic the paper world.

    We can do better. It will not happen until clinicians themselves demand a better paradigm.

  2. Great points on the slow uptake by auditors and reimbursement mechanisms in adopting new care delivery avenues like telemedicine. The comment about the use of visual and aural substitutes to written documentation causes me some grief, however.

    A picture is certainly worth a thousand words. Which is precisely why we absolutely need the clear and pithy written description. It cuts through ambiguity, potential misinterpretations, and irrelevant or unremarkable clinical findings. The picture, video, or other proof is just that—to substantiate the written text.

    Advanced EMRs have already changed the way physicians document the care and services rendered. Macros (e.g., SmartTexts) and problem-based pathway templates are just a couple examples of the system automating the written text with the pushing of buttons or the selection of drop-downs.

    The issue is that the “elegance” by which the system operates varies dramatically. The resultant “report” may have so much information that it is on par with what an anal-retentive first-year medical student may write, or too much of the needed details are missing to where time would be wasted with follow-ups and inquiries.

    What many of us have already known is that the elegant EMRs cater to different audiences. It allows the resident to quickly catch the summary details, yet it also provides HIM coders the fullest details of the care rendered. That multi-purpose role just cannot be adequately fulfilled by 2-dimensional paper. Which is why the exchange of the data between systems so that the data can be presented dynamically to the different consumers is ever so much more critical.

    Let’s be realistic. Any p-shifting is going to be slow. This is an evolutionary process, not revolutionary.

  3. When this paradigm shift occurs and data analysis is able to statistically determine how effective and efficient a provider and a unit within a provider are, will physicians be willing to accept the commoditization of their services? More importantly will they be willing to accept the reduction in salaries which results?

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