Electronic Health Records/Defiling Physician Performance

9/10/10

Concept Document: EHR/ Physician Interface

Electronic Health Records (EHRs) are inevitable and will be mandatory for economically viable medical practice in the next 5 years. It will be impossible to practice without them because,

1. ePrescribing will become statutorily required for patient safety.
2. Physician culture will become interconnected in electronic information exchange; this will be de rigueur.
3. With filing services for reimbursements, physicians will need the technology to,
   1. Maximize payment by optimal coding of all service charges to payers.
   2. Decrease or stabilize personnel costs by turning tasks over to IT.
4. Many physicians will move toward employment by bigger entities (hospitals, multi-specialty clinics, etc.) and those will use EHRs as an operational necessity in storing, exchanging, and standardizing information and procedures/practices. IT will bring about uniformity/ conformity.

Recognize that the “medical record”, over the past 20 years, has bifurcated into two entities,

1. A patient care/ case record
2. A medical resources/ charges audit document

It will probably take 20 years for IT to evolve and mature in the hands of physicians, and for those over 50 years old (least comfortable with handling it) to retire. That period will be marked by a great deal of inefficient work- time lost (that is not paid) in handling information with devices that are not as fast as pen and paper. Although having vast, well archived data quickly accessible will bring about overall time-saving and improved professional performance, there is a huge problem that IT engineers will not see.

The interface between the physician and the EHR must be a hybrid between the EHR/IT system and the conventional ways of entering information- writing and dictating. The collection of information at the point of care by a doctor is a qualitatively unique moment and process, probably not well understood even by them. Doctors spend decades internalizing massive amounts of complex information, depositing it in memory files and trees with infinite interconnections. That information is retrieved in specific and intangible ways when interviewing a patient to construct a scenario that achieves a number of things,

1. Identifies problems/ impressions,
   1. Active
   2. Inactive
   3. Relevant/ Irrelevant
   4. Priority
2. Risk stratification
   1. Priority list
   2. Criticality
      1. Time- dependant
      2. Morbidity- mortality risk
      3. Ultimate impact on function/ life
      4. Age infirmity
3. Focus of attention,
   1. See above
   2. Suffering
4. Necessity of expert help
5. Assessment of patient’s perceptions, fears, and priorities
6. Process patterns,
   1. Acute, sub-acute, chronic
   2. Constant
   3. Cyclical
   4. Intermittent
   5. Chaotic
   6. Progressive
   7. Mild, moderate, intense, etc.
7. Process extent,
   1. Local
   2. Systemic

In order to move toward a diagnosis and treatment plan for any given problem, during the interview the physician, for each problem, is thinking on a number of levels,

1. Anatomy: macro/ micro
2. Physiology: normal bodily function
   1. Pathophysiology: Dysfunctional or disease-affected physiology
3. Disease/ Injury mechanisms,
   1. Infections
   2. Toxic/Chemical
   3. Degenerative
   4. Traumatic
   5. Malignant
   6. Metabolic
   7. Inflammatory
   8. Etc.
4. Influencing variables:
   1. Activity
   2. Position
   3. Medications
   4. Physico-chemical
   5. Physical stress
   6. Etc.
5. Specific disease characteristics/features,
   1. Contagious
   2. Acquired
   3. Familial/ hereditary
   4. Natural history
      1. Possible patterns (presentation, course, organ-systems)
   5. Organ involvements
      1. Local, multi-organ, systemic
   6. Risks: damage, fatality
6. Timing: the point in the patient’s illness or story that the problems are being presented with respect to specific, potential diseases- early, midpoint, late/advanced.

The point is, a physician’s mind is a white sheet of paper that takes facts in, nuanced by his/her experience, expertise, biases, and wisdom, in a multivariate way, probably differently each time- because every patient is different and so the interaction is unique: communicability, fluency, articulateness, emotional repertoire, emotional state, educational level, fund of knowledge, biases, preconceptions, age, sex, psycho-emotional problems, healthcare experience, religion, philosophical values.

So, the interview is anything but an exercise in linear, IT “tree” pathways. IT builds and archives information that way, but a physician’s trained mind is an instrument of data collection, comparison, weighting, and connection in a complex, dynamic process that leads to ideas and impressions (which translate into specific medical and medical insurance vernacular- diseases, organ/ test abnormalities, physical/physiological dysfunction, etc.), colored by risk-benefit and time-criticality, as well as diagnostic/ treatment action plans.

When a physician is compelled to carry out this process in a static data entry IT “tree” hierarchy, the dynamism of medical integrative thought process (sometimes called the “art of medicine” or expert intuition) is dissembled, and the value and essence of the physician’s training, experience, and knowledge is seriously denatured and subverted. Physician “thinking” is more analogous to a spider web across which his mind travels in, out, across, under, over; and on multiple webs- all the while pulling from a knowledge base organized as “folders” along “trees”. In fact with the current IT approach, he/she becomes a data-entry clerk, rather than an incomparably capable data collection/ integration device. This would be true for anyone who is a master at an extraordinary level: music conductor, artist, writer, attorney, architect, etc.

In a word, by breaking the process down into component actions, the mastery is gone. Dissembling a car into all its component parts onto a garage floor leaves a pile of junk and debris, not a high-performance machine with a purpose. This is what doctors will experience and react to as they are forced into IT interfaces imposed on them by IT specialists, employers, etc.

With time, they will learn how to not think, or be unable to fire-up the long dormant integrative engine.

This is where there is the opportunity- to craft an IT interface that is a hybrid, a bridge between current physician culture/mindset and the EHR data tree format. On the most fundamental level, this hybrid model could be achieved by,

1. Physician information recording by electronic writing/ digital dictation.
2. Direct linkage, visually, of the doctor- collected information to the EHR demographic file for a patient.
3. Contemporaneous (as the medical record is being formed) display of EHR functions essential to physician responsibility and performance,
   1. Diagnosis coding
   2. Diagnostic test ordering
   3. ePrescribing
   4. Medical record forwarding function,
      1. To staff
      2. To other physicians
4. Templates: Common, recurrent clinical problems and scenarios formatted in electronic forms with interactive capability.

Optimally, these functions would be displayed on one screen at a time, to be expanded, visually, as needed.

The support staff (or a medical record search engine function) could then review and retrieve proper elements from the physician’s dynamic, less formed record (notes) and insert those elements, after the fact, into the EHR format, for later rapid review and approval by the physician. The physician can then “sign-off” on the finalized medical record and the resulting service code, approving it for submission to the payer.

In this way, over time, the physician will benefit from much better patient records and data, and accessibility to them, as well as many patient care functions and features previously neglected or unavailable.

This type interface model could be built with H7 healthcare software criteria and should be adaptable to multiple EHR products. This would be a tool for adapting a physician’s work process and data collection/ integration technique for transfer/ translation of the physician work product by non-physicians into EHR formats/conventions, as well as collection and formation of proper coding/ billing data. It will likely require joining disparate products/ technologies. That “connector” product and the work-flow process would be the subject of patents.

                                                                                    E. Rensimer, MD