Meaningful Use of Electronic Health Records by Doctors

In the past few weeks, my mother, mother-in-law, son, and daughter have had doctors' visits in which the doctor gave them a number of instructions. In each case, they would have benefited from a printed list of doctors' orders, which should be well within the capabilities of their doctors' systems. They won't go to the Internet to see their medical records, because of the seniors' limited use of the internet, or adolescent disinterest.

Yet our dog's veterinarians print out their orders routinely and immediately, which can be very helpful.

Let's insist on getting medical care as good as our dogs get! Stay tuned to this page for instructions on how to give your input to the Federal rule-makers who are now in Stage 2 of defining the minimum requirements for a doctor's "meaningful use" of an electronic health record. Your input will be helpful now, and in setting the agenda early on for Stage 3.

Our comments will pertain to Sections 170.314(e)(1) and 170.314(e)(2) of RIN 0991-AB82 of the proposed rule, as noted at 77 FR 13838-41 and 77 FR 18856-57.

You can see the entire specifications by the Office of the National Coordinator for Health Information Technology for meaningful use.

Beginner's Luck & the Darlin' Spector of Universal Health Care: Obama's First Hundred Days

Today was Barack Obama's 100th day as president, giving us wags an irresistible chance to bloviate.

Are you healthier than you were on January 19? Probably not. Will you be healthier in the future, based on the last 100 days? Probably so, though not for the reasons you think.

Pres. Obama chose a guy from Scranton, Pennsylvania as his vice president. Joe Biden had been commuting home from Washington DC on the train, sharing seats with passengers he came to know well – like Sen. Arlen Spector of Pennsylvania. Biden influenced Spector's decision to change his party affiliation, giving the Democrats a nearly filibuster-proof majority in the US Senate. And it significantly strengthens the chance of passage of legislation favored by Pres. Obama like the coming universal health care bill.

Today the Senate voted by 53-43 to accept the president's budget, which includes funding for universal insurance. Sen. Spector, along with all the other Republicans, voted No. Presumably the newly Democratic Sen. Spector will vote Yes in the future, adding a critically important vote to the slim majority for the very controversial universal health insurance bill, forthcoming by October.

The conservative Democrats who voted against the budget because of what they saw as its excessive funding will likely insist on cost controls in the future universal health insurance bill, according to today's NY Times. Electronic medical records are being touted for this purpose for their role in limiting costs. For example, an EMR might reveal to a doctor that an expensive test like an X-ray or CT scan has already been performed, saving costs and time in the hospital. Or the legibility of the EMR's typed doctors' orders and progress notes might prevent costly errors. Or the automatic reminders generated by the EMR might lead to the earlier detection and cheaper treatment of cancer. Of course, in addition to these financial benefits of the EMR are their savings of lives and suffering: fewer days in the hospital, invasive tests that need not be performed, less chemotherapy, etc.

Obama was lucky to have Sen. Spector become a Democrat. Arguably, he created his own luck by choosing the guy from Scranton as a vice president. Either way, the result is a higher chance of passage of universal health insurance, and of substantial financial support for the widespread use of electronic medical records.

The result, ultimately, in your life: you're more likely to get an automatic reminder from your doctor about your next appointment. When you call your doctor's medical practice at night and get a covering doctor on call, that doctor is more likely to have electronic access to your medical record, and to give you better advice. When you're in the hospital, the computer will be more likely to intercept would-be overdoses and wrong drugs.

And, if you’re one of the 50 million Americans who don't have health insurance now, you'll be more likely to get coverage, and health care, based on Obama's decisions, and luck, during the last 100 days.

These likely future improvements of broader health insurance and broadened use of EMRs add to those in Obama's first month.

All in all, not a bad start in improving public health.

The magician, not the wand: Wise use of the electronic medical record

Dr. Matthew Heller's comment:
Having been in solo practice for rheumatology for 34 years, I know that it's the magician, not the wand, that provides better health care. Although I use electronic medical records in my office, I do it in a way that does not interfere with listening to patients, making eye contact and practicing medicine in the way that I was taught 40 years ago.

It's not just privacy that’s at stake. More often than not electronic records spit out boilerplate data (often laden with errors) that get transmitted from one doctor to another completely devoid of any semblance of human interaction.

My vote is for the better practice of medicine, not the better use of computers.

Advice: Find a doctor who uses an electronic medical record as a useful tool, while preserving rapport and attention with you while in the exam room.

Read one patient’s observations on this.

Thanks to Dr. Heller for his letter to the editor, published in today’s New York Times.

He doesn’t want to read the list: Illiteracy, patient compliance, and the electronic medical record

Dr. Erin Marcus’ story

Last year, the community clinic where I work began requiring patients to go elsewhere for their blood and urine tests. For some patients, this has posed insurmountable obstacles, for shameful reasons.

One patient, compulsive about keeping his appointments with me, consistently fails to see specialists I recommend, and to have tests performed elsewhere. He always has an excuse.

And so I am stuck with a pleasant, complicated patient and no way to monitor the effects of the medicines I have prescribed.

Why is he non-compliant? Probably because he can’t read the map or directions I gave him, though he’ll never admit it – like many patients. In fact, one in seven adults in the U.S. has "below basic" prose literacy, i.e., they cannot read simple text. It is particularly hard for these patients to navigate the healthcare system, and their doctors are left without basic diagnostic information they need to provide good treatment.

Our comment:
Too bad they didn’t have Dr. Kalow. My son’s former pediatrician was Dr. Bruce Kalow, the doctor you wish you had. On his own initiative, during evenings at home after seeing young patients in his working class Somerville, Massachusetts community, Bruce developed a medical software program. His program improves communication with his patients and their families, many of whom primarily speak Spanish and Portugese, often with low literacy in English. At the end of the visit, he types briefly into his personal computer, which prints a sheet for the parent (and the doctor’s office) about the diagnosis, treatment, prescription, and follow-up instructions. When needed, the program readily provides the information in Spanish or Portugese.

Advice: Tell your foreign-born friends with little English literacy to look for a nearby doctor who routinely provides written summaries to patients in their primary language.

Read the source story by Dr. Erin Marcus in the July 24 New York Times.

It's not 20th century: Electronic medical records and patient waiting times

Barbara Duck:

"I've always loved [my medical practice], they treat you like family," says patient Josh Dryman, a 33-year-old who lives in Laguna Niguel, California. "But I had to wait an hour in the lobby and wait in the exam room another half-hour. Now [that they have an electronic medical record], when you go in, they get you in right away and the staff seems a heck of a lot friendlier."

Most of the time it is pretty easy to detect once you walk in to a lobby of a practice, those still using paper seem to possess an atmosphere of chaos to some degree, and the entire staff appears rushed and somewhat stressed, whereby those offices using electronic records have much of this information at their fingertips on the computers, thus less physical movement in pulling charts, looking for faxes, etc. and this in itself allows the office to focus better on patient care and not chasing information.

"The average consumer takes it as a given that doctors have these systems in place," says Peter Lee, chief executive of the Pacific Business Group on Health, an employer coalition based in San Francisco. "They don't know how much medical care today is not 20th century, let alone 21st century, in terms of how much doctors rely on paper instead of computers."

Nationally, only about 20% of physician offices are computerized; the rest still rely on notoriously inefficient paper charts. But computers are an easy benchmark for quality. They can help a doctor not just keep track of files, but also send out prescriptions accurately and quickly, get lab results inserted into the record automatically and be reminded what the scientific evidence suggests is the next best step with a patient.

Advice: In choosing a physician, ask whether s/he uses an electronic medical record to look up lab results, allow lookup of your record during evenings and weekends when you are sick, reduce medication errors, foster email communication with patients, and generally join the 21st century.

Read a story on an exemplary health care provider with odd and useful electronic medical record recommendations for patients, or read more from the source blog post.