Curbside Consult with Dr. Jayne 1/13/14

This is the last of a three-part response to a reader’s comments on EHRs (Part 1, Part 2.)

What is meaningful for the government is not meaningful for the patient. We sacrifice good care so the government can collect statistical data for free.

I’ve written on this topic before. It’s easy to play armchair quarterback and to dissect things through the retrospectoscope. Surely parts of the program might be different if the creators had it to do over again. I personally don’t like to be penalized for poor outcomes. It doesn’t matter how motivationally I interview, how well I design care plans, how well my team works with the patient, etc. – sometimes patients simply don’t want to do the right things for their health. Sometimes they are genetically doomed regardless of what we do. Sometimes they can’t afford to do the things we recommend, or choose to prioritize other needs or wants.

Most physicians are genuinely motivated to help people live longer, healthier lives (sometimes to the detriment of quality of life, but that’s another topic for another day) and are personally burdened when we can’t make someone better. Adding financial penalties for things which are not entirely under our control is offensive to those of us who work our tails off trying to do the right thing.

You want to ding me for failing to put someone with proteinuria on an ACE inhibitor or an angiotensin receptor blocker? Fine, I deserve it. You want me paid less because I write bad prescriptions that no one can read? Great. But don’t penalize me because Uncle Sal won’t get a colonoscopy despite a decade of counseling, discussion, debate, and downright begging. I’ve done all I can do.

As far as the “free” factor, technically we’re being compensated for our data through the various quality reporting initiatives, as well as through MU, so saying we’re giving it away for free may not be entirely accurate. Most of the clinical quality metrics revolve around good care, so it’s hard to argue that quality is sacrificed. But I respect the comment.

I’m generally not a fan of the conspiracy theories, but I wonder if the government wants to slow us down so they pay for less visits and care? We’ll never know the truth, but what better way to slow us down than Meaningful Use?

I admit I’ve had this thought before. Nationally, many physicians are refusing to accept Medicare, refusing new patients, or limiting their panel sizes, but it depends on your market. We have a lot of people that limit Medicare in our region because other insurers pay better and there’s plenty of demand, but that’s not the case everywhere. There are plenty of markets where Medicare is the top payer and physicians can’t afford to stop participating. The same applies to Medicaid. Several of my blogger friends hypothesize that it’s a ploy to get rid of primary care physicians and replace us with midlevel providers who are cheaper.

On the other hand, in our organization (and many others) we’ve figured out ways to comply with Meaningful Use and not slow down. This involves some extra clinical staff (funded by increased office visits and clinical quality payments as well as crafty negotiations with payers to embed care managers in our group) and a ton of additional training, but we’re generally still seeing the same number of office visits as we have. There have been fluctuations due to the recession when you look at our five-year vs. 10-year data, but most providers still have capacity to expand and we’re still hiring physicians.

I love computers and believe in the EHR concept, but it has to be done right. I’ve yet to see a good EHR. Computers are not smart machines. They are very fast and very loyal to the programmer. The main problem with EHR design sits in the knowledge and experience of the designers, who are:

a) Programmers without medical knowledge

b) Physicians without programming knowledge

c) Reputable professors with lots of published papers without ward clinical experience

d) Physicians who have graduated medical informatics programs but without clinical knowledge

e) Physicians who have clinical experience and some programming knowledge

f) Good physicians with good programming knowledge, which is ideal, but I don’t know if there are any involved in EHR design at this time

I saved this comment for last because it’s my favorite and the most near and dear to me. Although the gulf is closing, there are still significant gaps between clinical needs and programmers. It’s a challenge for vendors to hire people who can translate a physician business case into something the programmers can address, and to translate the limitations of the product into something to which users can respond.

Although there are some good physicians out there who have formal informatics training but minimal clinical experience, I’m always leery of them. When I meet one who didn’t complete an internship and never had a license, that’s a red flag for me. Whether justified or not, I feel that completing an internship and having had an actual medical license at least once in your career is essential. It’s even more essential when you’re going to be in a role where you tell other physicians how to behave.

Having been board certified at least once is nice too. You don’t have to keep your license forever and I don’t care if you maintain your board certification, but I want you to have gone through what the rest of us have gone through just as a point of understanding.

I’d also add another element – product management teams that respond to sales feedback preferentially over the feedback of existing users. Those who haven’t purchased an EHR don’t know what they don’t know, where current users definitely know what bites them on the posterior every day. I’ve seen good products decline when prospects demand functionality that although sexy isn’t built for the long haul.

As a farm girl, I think about it like I think about buying a truck. Although the quad cab with heated and air conditioned leather seats and a bus-load of chrome looks really good to someone who’s not a farmer, it’s kind of silly when you think about the fact that you’re going to be climbing into it with mud on your jeans and manure on your boots. When the motor on the power window dies, I’m going to be wishing I had a crank because I’ll be roasting to death driving while the younger cousins throw hay bales on the trailer.

Regarding the lack of good physicians with programming knowledge being involved in EHR design – as recently as three to five years ago I would have said the same thing. It’s still true at some vendors, but thank goodness ours have seen the light. Both our ambulatory and acute vendors have significant physician participation in design with both employees and clients involved. The staff physicians have substantial clinical experience and programming knowledge and work to translate user needs to the developers and to make sure what is coded actually works. Existing customers are becoming more savvy and vendors have to respond. It’s embarrassing to have physician users who know the product better than the vendor does, but I’ve seen it. A smart vendor will hire those physicians to be on their development teams if they can lure them away from practice, but it’s rare.

I’ve seen more vendors doing formal usability work throughout the design process, but it’s still not enough. What I’d really love to see is a vendor create a “model practice” that it can use for its development test bed. It should be a medium-sized multi-specialty practice. 

For starters, they could learn what practices have to go through even before they think about EHR including licensing, credentialing, professional liability, OSHA, CLIA, and the rest of the alphabet soup it takes to get the doors open. They can fully understand the staff dynamics of a medical practice (which seem different from many other industries) and what it’s like to be responsible for people’s lives and livelihoods. They can feel what happens when payers are slow and see how well their system does managing all the insane scenarios we deal with on a daily basis. And only when those physicians sign off on the content and usability should it ever be allowed to proceed to even a beta installation at a paying client.

I’ve not heard of a vendor doing this but if you have please, let me know. I’d love to get a dialogue going with my vendor about why that makes sense. I might even be crazy enough to volunteer for it. And if you’re a vendor, I’d enjoy hearing from you about how you use physicians in development. It would make a great topic for a future Curbside Consult. I’ll run your comments openly or anonymously if needed. Got docs? Email me.

Email Dr. Jayne.