Recently, internal medicine specialists converged upon the Boston Convention Center for the 2015 ACP Internal Medicine meeting. In the spirit of celebrating the 100th anniversary of the organization, ACP brought out world-class faculty who presented workshops on the latest advances in clinical science, practice management, physician leadership, healthcare policy, mHealth technology and medical informatics.
Peter Basch, MD, MACP spoke about hot topics in informatics policy that have relevance for medical practice processes and patient care. Dr. Basch is Visiting Scholar in Economic Studies at the Center for Health Policy at the Brookings Institute. He also serves as Medical Director for Ambulatory EHR and Health IT Policy at MedStar Health in the Baltimore-D.C. area. He is highly regarded for providing clinical and strategic leadership on EHR and IT policy, planning and implementation.
We spoke with Dr. Basch about these issues and more.
Q: What are the up and coming issues in medical informatics and how is this relevant to practice improvement?
Dr. Basch: From an informatics policy perspective, what I interpret as a growing theme that is apparently resonating with many leaders in our community… stepping back from a relentless push towards implementation and regulatory compliance, and asking the right questions.
Thus, now that ~80% of doctors are using EHRs in their practices, is it making a difference? And if so, is that difference more than just annoyance?
A survey came out [in early April] that should worry policy makers. It revealed that a growing majority of physicians are now comfortable with using EHRs; but there is also a corresponding decrease in the perception that the EHR is helping them to improve care. This finding throws cold water on yesterday’s conventional wisdom, which was that the neutral, to slightly positive, view of EHRs as tools to improve care would increase as EHR skillsets improved.
Further evidence that simply adopting an EHR and being a “Meaningful User” was not associated with better care or value came out in a recent CMS analysis of physician performance in the Medicare Shared Savings Program.
I believe we are seeing the response to this concern with Meaningful Use “course corrections” that step back a bit from the current approach of prescriptive process measures – to fewer ones, and with somewhat more flexibility. In theory, this should let doctors step back from an approach to EHRs that is “heads-down checkbox checking” to one that emphasizes EHRs as an advanced informational tool.
From the clinician perspective, it is (or at least should be) the next phase of EHR use, which is in a sense, “forget Meaningful Use” and start using your EHR and other health IT meaningfully. This approach is based on EHR as infrastructure and not a panacea; it requires specialty-specific differentiation, changes to workflow, and a commitment to results.
Bottom line: The trend is to forego magical thinking about technology infrastructure, and allow critical thinking and problem solving to return, but now being enabled by a health IT infrastructure.
Q: What is the one technology medical practices should be adopting today to change the efficiency and effectiveness of their services in the years ahead?
Dr. Basch: Devices that allow patients (or family / caregivers) to readily see and validate their key clinical information, as well as to easily provide relevant information to the clinician or care team at relevant points in care. What most clinicians would say is the most painful part of using an EHR is data entry; and specifically, filling information in many different fields (and that number of required fields seems to be growing daily). Of course, that pain is real, but it exists only because of a lack of imagination (and technology maturity)… it is analogous to asking a surgeon to grab the wrong end of a scalpel…
As a simple example, based on a clinician’s specialty and scope of practice—and a patient’s demographics, current complaints, med list, prior findings, etc.—there is a known and knowable list of useful information to obtain and validate at each visit. Having the EHR’s decision support queue these up for the patient (either to a portal or the patient’s personal device, or at the doctor’s office via a kiosk or tablet) “flips the visit” such that the patient validates information, answers relevant questions. and the clinician then views this information (in context). The office visit then shifts from the doctor being a data entry clerk to someone who reviews pertinent positives and negatives, and spends the bulk of the visit with the patient, and not the keyboard.
Q: What do physicians and practice managers need to know about the role of EHR and Ebola preparedness?
Dr. Basch: First, remember that the EHR is just a tool; it is not a substitute for sound judgment. However, if designed well, and all relevant users are trained and consistently use the right tools, an EHR can consistently present a key question(s) that make it far less likely that a suspect Ebola patient will “slip through the cracks.”
For example, in all of our outpatient sites, there is a single question that pops-up for every patient... every visit that asks about recent travel to the relevant countries in West Africa (or exposure). As long as the answer is “no” – it is a 3-second screening question that the doctor should never see.
However, if the answer is “yes”, and the follow-up question (relevant symptoms) is also “yes”, the EHR sets off a series of alerts… how to isolate the patient in a private exam room, putting appropriate signage on the outside of the door, the notification of other clinicians and infection control, etc.
Once the workflow of what should consistently happen is known (screening and what occurs when screening is positive), the EHR can then help to ensure consistent delivery of the appropriate messaging and education.