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Provider/Patient Relationship

Primary Care Corner with Geoffrey Modest MD: Electronic Medical Records Take Lots of Time

6 Oct, 16 | by EBM

By Dr. Geoffrey Modest

A recent AMA-sponsored study looked at the amount of time physicians spend on their various tasks, finding that for every hour spent on direct clinical face time care, roughly 2 hours is spent on the electronic health record (EHR) and desk work (see doi:10.7326/M16-0961).

Details:

  • 57 physicians (family medicine, internal medicine, cardiology, orthopedics) were observed for 430 hours in a direct observational time-and-motion study during office hours. In Illinois, New Hampshire, Virginia, and Washington
  • 79% men and 82% were aged 31-60.
  • 21 physicians also completed after-hours diaries for 7 consecutive days
  • They measured direct clinical face time with the patients, EHR and desk work (documentation/review, test results, meds and other orders), administrative tasks (insurance and scheduling), and other tasks (bathroom breaks, nonpatient care meetings, practice audits, EHR problems like crashing, etc.)

Results:

  • Overall breakdown of time on the different tasks:
    • 27% of the total time was spent on direct clinical face time with patients (and another 6% with staff and others, patient not being present).
    • 49% was spent on EHR and desk work, of which
      • 39% on documentation and review tasks, 6% on test results, 2% medication orders and 2% other orders
    • 1% on insurance issues and scheduling
    • 20% on other tasks (as above)
  • While in the exam room, 53% of the time was direct clinical face time and 37% was EHR/desk work
  • Of those completing the after-hours diaries, they reported a mean of 1.5 hours of time spent, 59% of which was on EHR tasks

Commentary:

  • These have been “interesting times” for clinicians, with pretty remarkably rapid transformations of how we see patients in the past 1-2 decades. One unfortunate result has been increasing physician burnout (a recent study found that 54% of US physicians have some signs of burnout, an increase from 46% from just 2011-2014). And other studies have confirmed what we in clinical care already know: our career satisfaction is largely dependent on time spent in meaningful patient interactions and the desire to provide high-quality care. Also, conversely, physician dissatisfaction tracks with the amount of time on paperwork/computer (see blog http://blogs.bmj.com/ebm/2015/12/22/primary-care-corner-with-geoffrey-modest-md-provider-computer-use-and-patient-satisfaction/ which documents both provider and patient dissatisfaction with computer use in the patient encounter). And these satisfying parts of patient care (which, i think, are the most important in terms of developing strong patient relationships, which are ultimately themselves therapeutic) are increasingly hard to do as more and more time-consuming demands confront us:
    • Dealing with patients’ clinical issues, along with the plethora of prior-approvals (PAs) for medications and radiologic studies, figuring out what meds to give patients as different insurers trim their lists of approved medications not requiring PAs, which referrals are “in” vs “out-of-network”,  keeping up with the increasing number of prescribed preventive services, following up on abnormal tests ordered by us or others (see below), figuring out how to deal with the community’s specific public health challenges which are now more knowable in the era of EHRs, etc.
    • And, in this context, dealing with the increasing time it takes to document, as required by EHRs. (i.e., “death by clicks”)
  • Even while in the exam room, only 1/2 the time in the present study was spent with direct clinical face-time with patients!!
  • Other issues, not in this study but I think which are part of the EHR syndrome:
    • False or excessive documentation: it is not uncommon to read extraordinarily long notes which undoubtedly do not truly reflect the actual patient encounter, but reflects the easy ability to cut-and-paste or click a button on the screen (e.g., the hand surgeon’s note which includes a complete review-of-systems and perhaps a full physical; or the ER note so encumbered with data and notes by an array of staff that it takes several minutes to find out what really happened)
    • Also, several of the EHRs do not integrate social/behavioral factors well into their documentation. As I think most of us learn in primary care over time, these factors are often some of the most important ones in treating patients’ medical problems, though they may take more time than just adjusting a blood pressure medication. We end up finding a work-around for this issue to include the psychosocial data, but it is not really formally integrated into the EHR (as has been strongly recommended by the National Academy of Medicine EHR report in 2014, calling for EHRs to systematically integrate social and behavioral determinants of health).
    • Many of the concerns about dysfunction of EHRs may reflect the fact that most EHRs are designed to optimize billing over providing optimal patient care (e.g., to focus on an easily billable medical diagnosis, instead of the psychosocial issues). It just doesn’t seem that the EHR designers really ever followed clinicians around who are actually practicing medicine to see what the important functionality needs to be to provide efficient care.
    • Another issue with the EHR is that it does provide access to much more information. For example, when the patient goes to the ER and has a CT scan, we in primary care can easily see the results (and probably are medico-legally responsible for follow-up if an abnormality is found). Clearly, this more-coordinated care is likely to be important for the patient, and is moving our systems to allowing for a more interconnected and coherent approach to patient care. But, it takes time. And, our reimbursement systems have not responded to that (e.g., I work in a neighborhood health center, on salary. But reimbursement by the insurers has really not changed significantly even though it takes much, much more time to see patients, leading our health center and others to still need similar levels of “productivity” in order to continue to function, which translates into seeing about the same number of patients in a clinical session, which leads to very long clinical sessions which often extend into evenings/weekends at home).
    • The EHR has made many of us long for the old, often illegible, but really fast-to-use and more patient-friendly paper medical records…

Primary Care Corner with Geoffrey Modest MD: Are Healthcare Metrics Good for Our Health?

26 Jan, 16 | by EBM

By Dr. Geoffrey Modest

The NY Times had a recent editorial by Robert Wachter, a professor of medicine at UCSF, suggesting that focusing on specific metrics/measurements may distort good quality care (see http://www.nytimes.com/2016/01/17/opinion/sunday/how-measurement-fails-doctors-and-teachers.html?emc=eta1&_r=0 ). [Thanks to Karen Henley for bringing this to my attention]. His points:

  • It is important to use metrics as part of the assessment of health care quality purview
  • There certainly is a basis to look at some issues of health care maintenance, or trying to decrease medical errors
  • But,
    • “There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a ‘top 100’, ‘honor roll’, ‘grade A” or ‘best hospitals’ list”
    • Electronic medical records are supposed to help with the metrics/quality, but a 2013 study showed that they were the leading cause of doctor burnout, and ER doctors click a mouse 4,000 times during a 10-hour shift. [And, I would add, computers can decrease many aspects of quality, such as really listening to the patient and having good, empathic eye contact. See http://blogs.bmj.com/ebm/2015/12/22/primary-care-corner-with-geoffrey-modest-md-provider-computer-use-and-patient-satisfaction/​ ]
    • He argues that “measurement cannot go away”, but that what we measure should be important clinical targets [I.e., not just the easy computer-generated claims-based ones], and that clinicians should be involved in the process of determining those metrics. He contrasts a really good measurement (certain hospital-acquired infections) with probably less useful ones (e.g., did the provider provide discharge instructions on asthma?, which is may be just remembering to check a box and giving the patient some pieces of paper, which they often do not look at later, without even going through the intended comprehensive patient education). And there needs to be a way to make these targets appropriate for different populations
  • But,
    • There are innumerable times that I get healthcare insurers sending me notifications that my nonhypertensive, nonproteinuric diabetic patient is not on the preferred ACE/ARB (and diabetes organizations have stated that these are not appropriate, for at least the last couple of years). These “reminders” add to the dramatically increasing amount of paperwork/emails/computer work that consumes my day…
    • I am put in a conflicting position: pretty commonly, I have patients ​come to me who have not had an A1c for the past 4-6 months, where getting the test is clinically useless. A frequent scenario is that they were out of the country for a few months and ran out of their meds (and Medicaid, a frequent insurer for my patients, will not give more than a 30-day supply of meds and they cannot be picked up early). So, when the patient returns to see me, their blood sugar is high, I reinstate their meds, and plan, appropriately I think, to check their A1c in 2-3 months. BUT if I do not check the A1C in the earlier visit, I get zinged by the insurance company (which I might get anyway, since the A1C will be “uncontrolled”), which affects the income to our health center.
    • Paying attention to some of the metrics takes time away from what may be the most important patient issues (getting a lot of testing may undercut my and the patient’s focus on the real issue: the fact that they are now homeless, do not have any income, are victims of domestic violence….  and that should take precedence). The point is that providing high-quality health care reflects a complex provider-patient relationship, where we (provider and patient) are sorting through an array of potentially complex medical, psychological/psychiatric, and social/behavioral issues, and by being pushed to focus on the mammogram or A1C, or discussing the risks and benefits of low-dose chest CT in smokers, is really a distraction in our way-too limited time together.
    • And, pay-for-performance (PFP, the system by some insurers to financially reward clinicians or their groups for adhering to the metrics) in studies a couple of years ago mostly showed that well-organized and well-funded, mostly middle-class organizations did well (and got extra money), and they did well on these metrics even before there was PFP. Less well-funded institutions did not get the monetary benefit of the PFP money, and really needed more money to help set up better organized systems.
    • So, I am certain there are lots of inefficiencies in the current system and that we as clinicians have missed important chances to provide accepted preventive interventions. And I support the concept of reminders and setting up systems in the practice to improve our performance (though the thrust in “poorly-performing” practices should be to help them financially and organizationally in improving their systems and not effectively decreasing their income). But these reward systems need to be appropriate clinically, derived from the local community needs, vary depending on the community (e.g., in some communities, rewards should be greater for screening for domestic violence, abuse, etc than A1C levels), be flexible enough to allow for clinician/patient discretion in their encounters (and dealing with social issues may happen much more often in some communities/clinics, such as a “healthcare for the homeless” clinic, where holding them to the same % target for some preventive services may be less appropriate), and be focused on helping practices in providing high quality care for their specific communities.

Primary Care Corner with Geoffrey Modest MD: Provider Computer Use and Patient Satisfaction

22 Dec, 15 | by EBM

By Dr. Geoffrey Modest

A small study was just published as a research letter looking at the impact on patient satisfaction when providers use computers in the exam room (see  doi:10.1001/jamainternmed.2015.6186.). This was an observational study done from Nov 2011 to Nov 2013 in an academic safety-net public hospital in San Francisco.

Details:

  • 47 patients (mean age 56.5, 55% women, 57% Hispanic/17% African-American/15% Asian/6% white, 55% primary Spanish speakers, 54% with high school education or less, 30% with inadequate health literacy as determined by their ability to fill out medical forms), and 39 clinicians (mean age 43.7, 64% women, 72% in primary care, 72% MDs, mean 13.9 years since getting professional degree)
  • Provider-patient relationship was <1 year in 16%, 1-5 years in 54% and >5 years in 30%.
  • Mean visit length was 24.6 minutes
  • Clinician computer use was low in 27% of encounters, moderate in 38% and high in 35% (this score was compilation of time reviewing computer data, typing or clicking with mouse, lack of eye contact with patient, and noninteractive pauses)
  • Rapport building included positive (laughter or agreement), negative (criticism or disagreement), emotional (empathy or partnership), and social (“chit-chat”) behavior
  • Encounters were videotaped and analyzed

Results:

  • Patients’ views in encounters with high computer use vs low:
    • Care was rated as excellent in 48% vs 83% (p=0.04)
    • There was more social rapport building by the patient (e.g. “you are wearing your hair that way…”; p=0.04) [though the authors note that in these high computer use encounters, this may not come across as “authentic engagement” and may lead to missed opportunities for developing deeper patient connections]
  • Patients in encounters with moderate computer vs low, computer use had less positive rapport building (e.g. “thank you”) (p<0.01) but had more positive affect tone (p=0.02)
  • Clinicians in encounters with high computer use:
    • ​Engaged in more negative rapport building (e.g. “no, it looks like your specialist filled that medication for you, it has a refill”; p<0.01)
    • ​Demonstrated less positive affect

So, as we head more and more towards computers being an integral part of the encounter (ménage-a-trois), there are some very real concerns:

  • It is really clear to me that it is in the history-taking that the vast majority of diagnoses and treatments are based
  • And, a therapeutic provider-patient relationship is really important in patient outcomes (and, I think, really very important in provider satisfaction as well)
  • But a computer intervening in this relationship, not surprisingly, undercuts these:
    • The computer systems I have seen (which are several of them) require focusing on the screen and, to some extent, pursuing questions as dictated by the screen. This is because much of the input is not free-text writing (which some of us can do without looking at the keyboard/screen), but navigating to sections of the screen, pushing on buttons there or filling in specific areas of the screen. And to the extent we are pursuing questions as dictated by the screen, we are not using the extremely important and often fruitful open-ended questions and then following up on the patient answers
    • There is much more information to process than in the good (and bad) old days. The good part is that we have the consultant notes, lab reports, results of ER visits right there. The bad news is that we spend a lot of time looking at these results, leaving less time to focus on the patient in front of us (and, overall it is probably better care to have quick access to all of this information, and in a way that is readable, as opposed to the old written medical records. But there is a price to be paid in terms of time and attention to the patient….)
  • So, what can be done?
    • I think that, at a minimum, it is useful to spend the first 5 or so minutes of the encounter just talking to the patient and having consistent eye contact.
    • ​And, of course, I think it is fundamentally absurd that those of us in primary care, who deal with pretty much all of the patients medical and psychosocial issues, have so little time to spend with the patient — to get to know the patient as a person and develop a caring relationship, get a good and accurate history, be able to help the patient to the extent we can, and to avoid unnecessary (and quite costly) visits to the ER or specialists for patient needs we could have taken care of in the first place.

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