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It promises greater convenience and speed for delivering basic health care services — but it isn’t what patients really want.\u003c/p>\n\u003cp>Retail thinking views patients as consumers: faceless targets for buying services and products that aren’t always health-related. It’s the thinking behind technology-assisted health care services, like ZocDoc, Amwell, and One Medical, which quickly triage symptoms or serve up medical advice. It’s the thinking that makes it possible for me to walk in, no appointment needed, to my local CVS or Target to have a cough or sore throat examined.\u003c/p>\n\u003cp>At the same time, it gives web-based apps \u003ca href=\"https://www.reuters.com/article/us-health-apps-privacy/health-apps-often-lack-privacy-policies-and-share-our-data-idUSKCN0WA2KE\" target=\"_blank\" rel=\"noopener\">opportunities to sell\u003c/a> some of your information to advertisers, who want to sell you other things. It gives brick-and-mortar organizations cross-selling opportunities for everything from allergy medications to Halloween candy as I walk down the store aisle to get my flu shot from the pharmacist or have the nurse practitioner apply guideline-driven diagnosis and treatment. The providers I see during these interactions know nothing about me, offer little tailored advice, and the services they provide will be both limited and standardized in how they are delivered.\u003c/p>\n\u003caside class=\"pullquote alignright\">What patients want most in health care is something human and intimate, maintained through regular one-on-one interactions with experts they knew and trusted who were compassionate, empathetic, friendly, and respectful.\u003c/aside>\n\u003cp>Being viewed through the retail lens also means that I am asked to consume other offerings pitched to me by whoever provides me with health care, be it my insurance company or my employer. They try to get me interested in legal and babysitting services, gym memberships, pedometers, mail-order pharmacies, round-the-clock nurse help lines, life insurance, and more. They do this to help them earn more of my loyalty, generate more revenue for themselves, or reduce their costs.\u003c/p>\n\u003cp>The hospitals and medical offices I visit seek to keep me within their system of care delivery, make me a long-term customer, and refer me only to their providers and services, both of which they control. By using retail tactics like offering one-stop shopping — where I can get primary, specialty, and other types of care all without leaving the same building — and marketing their brand to me with simplified rating systems that show their high quality, they want me to trust that they have my interests at heart and can deliver any type of health care transaction I require.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Retail thinking has its place in health care today because there are some services and products that people need quickly and which do not require a personal touch or someone who understands them as unique individuals. Such services might be low-level acute care (think strep throat), flu shots and immunizations, and some forms of simple chronic disease management, such as blood sugar checks or foot and eye exams for people with diabetes, especially if they are guideline driven. There’s no question that retail thinking can also create purchasing opportunities for things patients find useful, if not always essential, and perhaps do so in ways that are cost-effective or convenient for us.\u003c/p>\n\u003cp>[contextly_sidebar id=\"qGlMknrKeKf4bI1E46uTCBwN0fHZychq\"]But retail health care is impersonal, lacks relational warmth, and isn’t what patients really want.\u003c/p>\n\u003cp>I interviewed 80 patients and doctors for a \u003ca href=\"https://global.oup.com/academic/product/next-in-line-9780190626341?cc=us&lang=en&\" target=\"_blank\" rel=\"noopener\">new book\u003c/a> on the doctor-patient relationship in the era of efficiency-driven innovation, corporate care, and retail medicine. What I heard from patients is that the impersonal nature of retail thinking is frustrating them and lowering their expectations about the levels of emotional support and customized help they can get from any doctor, or from others in the health care system.\u003c/p>\n\u003cp>No patient with whom I spoke wanted transactional care at the expense of relational care. No one prioritized \u003ca href=\"https://www.statnews.com/2016/10/04/fitbit-wont-improve-health/\">Fitbits\u003c/a>, web-based assessments of symptoms, or seeing a stranger about a sore throat in a big-box store over a long-term personal connection with a doctor. What these individuals wanted most in health care was something human and more intimate, maintained through regular one-on-one interactions with experts they knew and trusted who were compassionate, empathetic, friendly, and respectful.\u003c/p>\n\u003cp>The physicians with whom I spoke wanted the same things.\u003c/p>\n\u003cp>This type of sustained personal experience between two people who know something about each other, and who are motivated to really talk and listen as care partners, is something retail thinking does not do well. It is not concerned with the emotional aspects of care, building interpersonal trust between doctor and patient, or getting to know people as individuals with their own relevant life stories.\u003c/p>\n\u003cp>Yet existing research demonstrates that these are the very features that are good for patients. For example, \u003ca href=\"http://www.hpm.org/Downloads/Bellagio/Articles/Continuity/Cabana_MD_-_2004_-_Does_continuity_of_care_improve_patient_outcomes.pdf\" target=\"_blank\" rel=\"noopener\">care continuity\u003c/a> through a stable doctor-patient relationship improves health care quality and patient satisfaction. \u003ca href=\"http://onlinelibrary.wiley.com/doi/10.1111/1468-0009.00223/full\" target=\"_blank\" rel=\"noopener\">Doctor-patient trust\u003c/a>, established through extended interpersonal contact, helps patients become more engaged in their care; creates a positive patient experience; and increases perceived effectiveness of care. \u003ca href=\"http://www.sciencedirect.com/science/article/pii/S0738399108006319\" target=\"_blank\" rel=\"noopener\">Extended dialogue\u003c/a> between patient and doctor positively affects health outcomes ranging from high blood pressure to mental health problems. \u003ca href=\"http://bjgp.org/content/63/606/e76.full\" target=\"_blank\" rel=\"noopener\">Physician empathy\u003c/a> is linked to more accurate diagnoses, better health outcomes, and an enhanced patient experience.\u003c/p>\n\u003cp>[contextly_sidebar id=\"DXDu9yVu5UXGAwIZHglW19AkCubz5xhW\"]If you don’t believe the literature, just ask the patients I interviewed. Teddy, a healthy man in his 30s, believed that without feeling trust towards a specific doctor — which for him was forged over time through regular face time and conversations with that doctor — little could be uncovered of the more intimate, life story information that he felt was most important for keeping him healthy. He said he had never been completely honest with clinicians he didn’t know.\u003c/p>\n\u003cp>Hallie, a 50-year-old woman with several chronic diseases, talked confidently about better understanding how to manage her many conditions, and how they affected her everyday life — the result of having a doctor who knew something about her personally, who spent time not reading off a care guideline but instead asking her real-time questions about how she felt, and then showing genuine compassion with her daily struggles. Hallie felt better able to self-manage her care, which kept her from using the system unnecessarily.\u003c/p>\n\u003cp>Cliff, a stressed-out dad in his 50s, talked excitedly about finally having the same physician he could see on a consistent basis; a doctor who in their first visit had spent time just listening to him, nothing more; then taking that information and asking him questions about his own life; and finally tailoring therapeutic advice based on the entire dialogue. Janell, a career-minded mom in her 40s, recalled with joy the memory of a past primary care physician who remembered conversations they had during previous visits and who used that knowledge to give Janell tailored guidance about how to manage her life stressors more effectively.\u003c/p>\n\u003cp>Can an industry that wants to use retail tactics also deliver on the relational excellence that patients and research say is important? It’s not easy, given retail thinking’s focus on speed and efficiency. Here are four ways that might meld these two approaches.\u003c/p>\n\u003cp>First, put more thought into where \u003cem>not\u003c/em> to use retail thinking in health care. It may make sense for care delivery that is routine, care that can be standardized in a straightforward way, and in situations where the patient wants convenience above all else. But that actually amounts to a limited menu of services, and even routine care can often reveal deeper problems in patients, requiring the kinds of relational features I’ve described.\u003c/p>\n\u003cp>Second, better measure and monetize the components of relational excellence, making it matter to health care organizations and third-party payers. That means carefully assessing dynamics like interpersonal trust between doctor and patient; analyzing those data to see how they positively affect health outcomes; and then giving this metric the same relative importance in high-quality care delivery compared to other things like prescribing a particular drug for a particular condition.\u003c/p>\n\u003cp>Third, look for innovative ways to \u003cem>strengthen\u003c/em> the doctor-patient relationship, not undermine it. For example, the industry should experiment with using technology as a tool to give doctors more face time and direct contact with their patients. Right now, both doctors and patients perceive technology, primarily the electronic health record, as interfering with their relationship.\u003c/p>\n\u003cp>Fourth, and most important, the patient voice must be heard. This could include adopting greater transparency with respect to assessing patient satisfaction with retail tactics, say through \u003ca href=\"https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2015.1030\" target=\"_blank\" rel=\"noopener\">Yelp-type accountability mechanisms\u003c/a>, and conducting market research that goes beyond simple binary questions of “would you use this” or “would you like greater convenience in accessing your care” and instead delves deeper into discovering what patients really value.\u003c/p>\n\u003cp>In thinking about my discussions with patients, there is one other important thing they want. They want to decide when their health care should work like the drive-through at McDonald’s or buying with one click at Amazon and when it should be more personal than that, involving extended human-to-human interaction, highly trained experts who know their patients, and an abundance of the time, trust, and soft skills required to make us healthier long-term and see health care as the important part of our lives that it really is.\u003c/p>\n\u003cp>\u003cem>Timothy J. Hoff, Ph.D., is professor of management, health care systems, and health policy at the D’Amore-McKim School of Business and the School of Public Affairs and Policy at Northeastern University in Boston; a visiting associate fellow at Green-Templeton College and visiting scholar at Said Business School, both at the University of Oxford; and the author of \u003ca href=\"https://global.oup.com/academic/product/next-in-line-9780190626341?cc=us&lang=en&\" target=\"_blank\" rel=\"noopener\">“Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health”\u003c/a> (Oxford University Press, September 2017).\u003c/em>\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>This \u003ca href=\"https://www.statnews.com/2017/12/04/retail-health-care-patients/\">story\u003c/a> was originally published by STAT, an online publication of Boston Globe Media that covers health, medicine, and scientific discovery.\u003c/p>\n\n","blocks":[],"excerpt":"Retail thinking promises greater convenience for delivering basic health care services but doesn't offer the doctor-patient connection that improves health.","status":"publish","parent":0,"modified":1512673832,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":25,"wordCount":1698},"headData":{"title":"Retail Health Care Less Effective, Lacks Personal Connection Patients Need (Commentary) | KQED","description":"Retail thinking promises greater convenience for delivering basic health care services but doesn't offer the doctor-patient connection that improves health.","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Retail Health Care Less Effective, Lacks Personal Connection Patients Need (Commentary)","datePublished":"2017-12-07T08:01:46.000Z","dateModified":"2017-12-07T19:10:32.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"437450 https://ww2.kqed.org/futureofyou/?p=437450","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/12/07/retail-health-care-lacks-the-personal-connections-that-patients-want-and-need/","disqusTitle":"Retail Health Care Less Effective, Lacks Personal Connection Patients Need (Commentary)","nprByline":"Timothy J. Hoff\u003c/br>STAT","path":"/futureofyou/437450/retail-health-care-lacks-the-personal-connections-that-patients-want-and-need","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>Retail thinking is spreading quickly in health care. It promises greater convenience and speed for delivering basic health care services — but it isn’t what patients really want.\u003c/p>\n\u003cp>Retail thinking views patients as consumers: faceless targets for buying services and products that aren’t always health-related. It’s the thinking behind technology-assisted health care services, like ZocDoc, Amwell, and One Medical, which quickly triage symptoms or serve up medical advice. It’s the thinking that makes it possible for me to walk in, no appointment needed, to my local CVS or Target to have a cough or sore throat examined.\u003c/p>\n\u003cp>At the same time, it gives web-based apps \u003ca href=\"https://www.reuters.com/article/us-health-apps-privacy/health-apps-often-lack-privacy-policies-and-share-our-data-idUSKCN0WA2KE\" target=\"_blank\" rel=\"noopener\">opportunities to sell\u003c/a> some of your information to advertisers, who want to sell you other things. It gives brick-and-mortar organizations cross-selling opportunities for everything from allergy medications to Halloween candy as I walk down the store aisle to get my flu shot from the pharmacist or have the nurse practitioner apply guideline-driven diagnosis and treatment. The providers I see during these interactions know nothing about me, offer little tailored advice, and the services they provide will be both limited and standardized in how they are delivered.\u003c/p>\n\u003caside class=\"pullquote alignright\">What patients want most in health care is something human and intimate, maintained through regular one-on-one interactions with experts they knew and trusted who were compassionate, empathetic, friendly, and respectful.\u003c/aside>\n\u003cp>Being viewed through the retail lens also means that I am asked to consume other offerings pitched to me by whoever provides me with health care, be it my insurance company or my employer. They try to get me interested in legal and babysitting services, gym memberships, pedometers, mail-order pharmacies, round-the-clock nurse help lines, life insurance, and more. They do this to help them earn more of my loyalty, generate more revenue for themselves, or reduce their costs.\u003c/p>\n\u003cp>The hospitals and medical offices I visit seek to keep me within their system of care delivery, make me a long-term customer, and refer me only to their providers and services, both of which they control. By using retail tactics like offering one-stop shopping — where I can get primary, specialty, and other types of care all without leaving the same building — and marketing their brand to me with simplified rating systems that show their high quality, they want me to trust that they have my interests at heart and can deliver any type of health care transaction I require.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Retail thinking has its place in health care today because there are some services and products that people need quickly and which do not require a personal touch or someone who understands them as unique individuals. Such services might be low-level acute care (think strep throat), flu shots and immunizations, and some forms of simple chronic disease management, such as blood sugar checks or foot and eye exams for people with diabetes, especially if they are guideline driven. There’s no question that retail thinking can also create purchasing opportunities for things patients find useful, if not always essential, and perhaps do so in ways that are cost-effective or convenient for us.\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>But retail health care is impersonal, lacks relational warmth, and isn’t what patients really want.\u003c/p>\n\u003cp>I interviewed 80 patients and doctors for a \u003ca href=\"https://global.oup.com/academic/product/next-in-line-9780190626341?cc=us&lang=en&\" target=\"_blank\" rel=\"noopener\">new book\u003c/a> on the doctor-patient relationship in the era of efficiency-driven innovation, corporate care, and retail medicine. What I heard from patients is that the impersonal nature of retail thinking is frustrating them and lowering their expectations about the levels of emotional support and customized help they can get from any doctor, or from others in the health care system.\u003c/p>\n\u003cp>No patient with whom I spoke wanted transactional care at the expense of relational care. No one prioritized \u003ca href=\"https://www.statnews.com/2016/10/04/fitbit-wont-improve-health/\">Fitbits\u003c/a>, web-based assessments of symptoms, or seeing a stranger about a sore throat in a big-box store over a long-term personal connection with a doctor. What these individuals wanted most in health care was something human and more intimate, maintained through regular one-on-one interactions with experts they knew and trusted who were compassionate, empathetic, friendly, and respectful.\u003c/p>\n\u003cp>The physicians with whom I spoke wanted the same things.\u003c/p>\n\u003cp>This type of sustained personal experience between two people who know something about each other, and who are motivated to really talk and listen as care partners, is something retail thinking does not do well. It is not concerned with the emotional aspects of care, building interpersonal trust between doctor and patient, or getting to know people as individuals with their own relevant life stories.\u003c/p>\n\u003cp>Yet existing research demonstrates that these are the very features that are good for patients. For example, \u003ca href=\"http://www.hpm.org/Downloads/Bellagio/Articles/Continuity/Cabana_MD_-_2004_-_Does_continuity_of_care_improve_patient_outcomes.pdf\" target=\"_blank\" rel=\"noopener\">care continuity\u003c/a> through a stable doctor-patient relationship improves health care quality and patient satisfaction. \u003ca href=\"http://onlinelibrary.wiley.com/doi/10.1111/1468-0009.00223/full\" target=\"_blank\" rel=\"noopener\">Doctor-patient trust\u003c/a>, established through extended interpersonal contact, helps patients become more engaged in their care; creates a positive patient experience; and increases perceived effectiveness of care. \u003ca href=\"http://www.sciencedirect.com/science/article/pii/S0738399108006319\" target=\"_blank\" rel=\"noopener\">Extended dialogue\u003c/a> between patient and doctor positively affects health outcomes ranging from high blood pressure to mental health problems. \u003ca href=\"http://bjgp.org/content/63/606/e76.full\" target=\"_blank\" rel=\"noopener\">Physician empathy\u003c/a> is linked to more accurate diagnoses, better health outcomes, and an enhanced patient experience.\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>If you don’t believe the literature, just ask the patients I interviewed. Teddy, a healthy man in his 30s, believed that without feeling trust towards a specific doctor — which for him was forged over time through regular face time and conversations with that doctor — little could be uncovered of the more intimate, life story information that he felt was most important for keeping him healthy. He said he had never been completely honest with clinicians he didn’t know.\u003c/p>\n\u003cp>Hallie, a 50-year-old woman with several chronic diseases, talked confidently about better understanding how to manage her many conditions, and how they affected her everyday life — the result of having a doctor who knew something about her personally, who spent time not reading off a care guideline but instead asking her real-time questions about how she felt, and then showing genuine compassion with her daily struggles. Hallie felt better able to self-manage her care, which kept her from using the system unnecessarily.\u003c/p>\n\u003cp>Cliff, a stressed-out dad in his 50s, talked excitedly about finally having the same physician he could see on a consistent basis; a doctor who in their first visit had spent time just listening to him, nothing more; then taking that information and asking him questions about his own life; and finally tailoring therapeutic advice based on the entire dialogue. Janell, a career-minded mom in her 40s, recalled with joy the memory of a past primary care physician who remembered conversations they had during previous visits and who used that knowledge to give Janell tailored guidance about how to manage her life stressors more effectively.\u003c/p>\n\u003cp>Can an industry that wants to use retail tactics also deliver on the relational excellence that patients and research say is important? It’s not easy, given retail thinking’s focus on speed and efficiency. Here are four ways that might meld these two approaches.\u003c/p>\n\u003cp>First, put more thought into where \u003cem>not\u003c/em> to use retail thinking in health care. It may make sense for care delivery that is routine, care that can be standardized in a straightforward way, and in situations where the patient wants convenience above all else. But that actually amounts to a limited menu of services, and even routine care can often reveal deeper problems in patients, requiring the kinds of relational features I’ve described.\u003c/p>\n\u003cp>Second, better measure and monetize the components of relational excellence, making it matter to health care organizations and third-party payers. That means carefully assessing dynamics like interpersonal trust between doctor and patient; analyzing those data to see how they positively affect health outcomes; and then giving this metric the same relative importance in high-quality care delivery compared to other things like prescribing a particular drug for a particular condition.\u003c/p>\n\u003cp>Third, look for innovative ways to \u003cem>strengthen\u003c/em> the doctor-patient relationship, not undermine it. For example, the industry should experiment with using technology as a tool to give doctors more face time and direct contact with their patients. Right now, both doctors and patients perceive technology, primarily the electronic health record, as interfering with their relationship.\u003c/p>\n\u003cp>Fourth, and most important, the patient voice must be heard. This could include adopting greater transparency with respect to assessing patient satisfaction with retail tactics, say through \u003ca href=\"https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2015.1030\" target=\"_blank\" rel=\"noopener\">Yelp-type accountability mechanisms\u003c/a>, and conducting market research that goes beyond simple binary questions of “would you use this” or “would you like greater convenience in accessing your care” and instead delves deeper into discovering what patients really value.\u003c/p>\n\u003cp>In thinking about my discussions with patients, there is one other important thing they want. They want to decide when their health care should work like the drive-through at McDonald’s or buying with one click at Amazon and when it should be more personal than that, involving extended human-to-human interaction, highly trained experts who know their patients, and an abundance of the time, trust, and soft skills required to make us healthier long-term and see health care as the important part of our lives that it really is.\u003c/p>\n\u003cp>\u003cem>Timothy J. Hoff, Ph.D., is professor of management, health care systems, and health policy at the D’Amore-McKim School of Business and the School of Public Affairs and Policy at Northeastern University in Boston; a visiting associate fellow at Green-Templeton College and visiting scholar at Said Business School, both at the University of Oxford; and the author of \u003ca href=\"https://global.oup.com/academic/product/next-in-line-9780190626341?cc=us&lang=en&\" target=\"_blank\" rel=\"noopener\">“Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health”\u003c/a> (Oxford University Press, September 2017).\u003c/em>\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>This \u003ca href=\"https://www.statnews.com/2017/12/04/retail-health-care-patients/\">story\u003c/a> was originally published by STAT, an online publication of Boston Globe Media that covers health, medicine, and scientific discovery.\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/437450/retail-health-care-lacks-the-personal-connections-that-patients-want-and-need","authors":["byline_futureofyou_437450"],"categories":["futureofyou_452","futureofyou_1"],"tags":["futureofyou_794","futureofyou_232","futureofyou_177","futureofyou_487"],"featImg":"futureofyou_437452","label":"futureofyou"},"futureofyou_434787":{"type":"posts","id":"futureofyou_434787","meta":{"index":"posts_1591205157","site":"futureofyou","id":"434787","score":null,"sort":[1503412259000]},"guestAuthors":[],"slug":"why-someone-thousands-of-miles-away-might-watch-your-medical-exam-with-google-glass","title":"To Lift EHR Burden, Doctors Live-Stream Patient Exams to Remote Scribes","publishDate":1503412259,"format":"standard","headTitle":"KQED Future of You | KQED Science","labelTerm":{},"content":"\u003cp>The familiar phrase, “The doctor will see you now,” is not what it used to be.\u003c/p>\n\u003cp>That's because during most exams, physicians are spending a good chunk of time not looking at the patient, but at the patient's electronic health record on a computer screen.\u003c/p>\n\u003caside class=\"pullquote alignright\">'We have invested a lot of time to train physicians, so why not have them use their expertise in the most efficient way possible?'\u003c/aside>\n\u003cp>A 2016 \u003ca href=\"http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties\" target=\"_blank\" rel=\"noopener noreferrer\"> study\u003c/a> in the \u003cem>Annals of Internal Medicine\u003c/em> found that physicians spent 37 percent of their time on\u003cstrong> \u003c/strong>a computer during exams.\u003c/p>\n\u003cp>The situation can be frustrating for patients, who don't think they are getting the doctor's full attention.\u003c/p>\n\u003cp>\"That most fundamental aspect of human communication, which is eye contact, now is being robbed from the medical encounter because of the electronic health record,\" says Dr. Lloyd Minor, dean of Stanford's medical school.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>While acknowledging the benefits of EHRs, which are meant to improve patient care by providing an easily accessible health history, physicians have also railed against the heavy amount of data entry they require. Physicians spend an estimated one to two hours after work completing EHRs and other \"desktop medicine\" requirements, according to the study in \u003cem>Annals of Internal Medicine.\u003c/em>\u003c/p>\n\u003cp>But now Dr. Albert Chan, the chief of digital patient experience for the Sutter Health Network, thinks he has a solution for the burden of EHRs. Chan uses \u003ca href=\"https://www.x.company/glass/\" target=\"_blank\" rel=\"noopener noreferrer\">Google Glass\u003c/a>, with its tiny camera mounted on a device worn like eyeglasses, to stream audio and video of the patient to an offsite medical scribe. The scribe sees and hears what the doctor does, writing the notes that go into the electronic health record. This frees up the physician to give the patient her full attention. Doctors can communicate with their note-takers through a headset, asking them to retrieve test results and other data. The scribe responds via text message, which the physician sees in the Glass lens.\u003c/p>\n\u003caside class=\"pullquote alignright\">'You’re just adding more layers of cost and people to assist in the exam room.'\u003c/aside>\n\u003cp>“For patients, it’s better care because the doctors focus on them, and the doctors spend more time with them,\" Chan says. He says that because the doctor’s attention is not divided between the computer and the patient, records of the visit are more accurate.\u003c/p>\n\u003cp>The system is provided by a company called Augmedix, of which Sutter Health is an investor.\u003c/p>\n\u003cp>Currently about 100 Sutter doctors are using the system. After first deploying it among physicians in internal medicine, Sutter is now expanding it for use by specialists like dermatologists, podiatrists and orthopedists across its Northern California network.\u003c/p>\n\u003cp>“I mean, we have invested a lot of time to train physicians, so why not have them use their expertise in the most efficient way possible?” says Chan.\u003c/p>\n\u003cp>\u003cstrong>Encounter at Dolores Park\u003c/strong>\u003c/p>\n\u003cp>Augmedix was founded in 2012, by Ian Shakil and Pelu Tran. Shakil, who is the CEO, says he got the idea after a chance encounter at San Francisco's Dolores Park with some Google employees who were working on Glass. \"They had Glass in their backpacks. And they let us try it on,\" he says.\u003c/p>\n\u003cp>[contextly_sidebar id=\"TXibesbDeLMGc9JYIC8IybWNpNcdvmaW\"]After the Google crew explained the product was intended for consumers, \"I got into a big argument with the group that this was really meant for doctors.\" (Glass was a notorious bust with the public, but is \u003ca href=\"https://www.wired.com/story/google-glass-2-is-here/\" target=\"_blank\" rel=\"noopener noreferrer\">now hitting its stride as a workplace tool.\u003c/a>)\u003c/p>\n\u003cp>Shakil, who knew from media reports and his own encounters with physicians that they were beleaguered with documentation requirements, says he became obsessed with the idea of using Glass as a solution. \"I couldn't sleep; I couldn't stop talking about it. I literally quit my job.\"\u003c/p>\n\u003cp>He then reeled in his friend Tran, who dropped out of his fourth year at medical school, and the two formed the company. Shakil says more than 1,000 doctors are currently using Augmedix across the U.S. , with the largest deployment by Sutter.\u003c/p>\n\u003cp>Besides Sutter, investors include health services company McKesson and Dignity Health network.\u003c/p>\n\u003cp>Sutter's Dr. Chan says the scribes provide a number of benefits, including reminding physicians to address issues they might otherwise miss.\u003c/p>\n\u003cp>“If you have shoulder pain and chest pain, for instance, well, if I forget to address the shoulder pain during the exam, I can get a subtle hint from the transcriptionist -- ‘Hey, you may want to address the shoulder pain, too.’ ”\u003c/p>\n\u003cp>Because doctors use shorthand when entering information in an EHR, Chan says, they often have to go back hours later and fill in the gaps; that isn't necessary when a third party is taking the notes in real-time.\u003c/p>\n\u003cp>\u003cstrong>'Oh, I Can See My Kid's Soccer Game'\u003c/strong>\u003c/p>\n\u003cp>About two-thirds of Augmedix's note-takers are located overseas, in India, the Dominican Republic and Sri Lanka, says CEO Shakil. But Adeeba Hasan, a full-time scribe for the company, works out of headquarters in San Francisco. Hasan says she's able to take 80 percent of the EHR workload off a doctor's hands. \"My doctors are able to leave and get home about two or three hours early,\" Hasan says. \"They definitely thank for me for little things like, 'Oh, I can see my kids' soccer game.' \"\u003c/p>\n\u003cp>She has scribed for 20 doctors, whose predominant perspective, she says, is that while EHRs are important, they don't require a medical degree to complete. She herself is applying to medical school and finds the experience valuable. \"I'm learning all about different medications and illnesses and how you talk to patients,\" she says.\u003c/p>\n\u003cp>\u003cstrong>A Doubter\u003c/strong>\u003c/p>\n\u003cp>So is this the future of medicine as we know it?\u003c/p>\n\u003cp>“Oh my God, I hope not,” says David Lansky, executive director of the Pacific Business Group on Health, a nonprofit consortium of private companies and public agencies working toward greater health care affordability and quality.\u003c/p>\n\u003cp>The Augmedix service generally ranges from $1,500 to $3,500 per physician, per month, according to Shakil. Lansky says fixing the dysfunctional health care system requires putting the brakes on runaway costs, and using expensive scribes does just the opposite.\u003c/p>\n\u003cp>“You’re just adding more layers of cost and people to assist in the exam room,” Lansky says.\u003c/p>\n\u003cp>He thinks the solution to the burden of EHRs is to lessen reporting requirements, from quality measures to insurance coding to language intended to fend off lawsuits\u003cb>.\u003c/b>\u003c/p>\n\u003cp>“The real problem is that administrative requirements are uncoordinated and useless,\" Lansky says. \"I mean, no one’s even looking at the quality measures physicians are required to key in.\"\u003c/p>\n\u003cp>“The two paths we want to pursue are to reduce reporting and improve EHR function. If everything’s in front of you, you can use your face time [with the patient] to really \u003cem>do\u003c/em> face time.”\u003c/p>\n\u003cp>\u003cstrong>What About the Creepiness Factor?\u003c/strong>\u003c/p>\n\u003cp>Might some patients, especially women, not take too kindly to having something as intimate as a medical exam observed by someone they don't know and can't see?\u003c/p>\n\u003cp>\"To be honest\u003cstrong>, \u003c/strong>\u003cspan class=\"s1\">when we first founded the business, we had no idea if this issue was going to be a show-stopper or not a big deal,\" says Shakil. \"We’ve since grown and we’ve learned that it’ s not actually a big deal.\" \u003c/span>\u003c/p>\n\u003cp>He says only 2 percent of patients have opted out so far, a rate that remains steady across all demographics, including sex.\u003c/p>\n\u003cp>Shakil says the audio-video stream is encrypted, so hacking is not an issue. \"We've penetration-tested it, and it's Fort Knox, basically.\" The scribes sit in what he calls an \"ultra-secure environment,\" with nothing in their pockets, video monitoring, and computers that can only run the company's application.\u003c/p>\n\u003cp>The doctor can also temporarily switch off the Glass feed by swiping or verbal command if there's something occurring the patient doesn't want transmitted. The light on the device changes color to indicate its no longer active, which the patient can see.\u003c/p>\n\u003cp>Interestingly enough, there is one small sub-group of patients who are opting out at a slightly greater rate.\u003c/p>\n\u003cp>\"It's a little bit higher around the Google campus than anywhere in the country,\" Shakil says.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>Make of that what you will.\u003c/p>\n\n","blocks":[],"excerpt":"Some physicians are now using Google Glass to allow offsite scribes to see and listen in on patient exams in order to take notes required for electronic health records, freeing doctors up to focus on patients.","status":"publish","parent":0,"modified":1503508393,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":42,"wordCount":1436},"headData":{"title":"To Lift EHR Burden, Doctors Live-Stream Patient Exams to Remote Scribes | KQED","description":"Some physicians are now using Google Glass to allow offsite scribes to see and listen in on patient exams in order to take notes required for electronic health records, freeing doctors up to focus on patients.","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"To Lift EHR Burden, Doctors Live-Stream Patient Exams to Remote Scribes","datePublished":"2017-08-22T14:30:59.000Z","dateModified":"2017-08-23T17:13:13.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"434787 https://ww2.kqed.org/futureofyou/?p=434787","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/08/22/why-someone-thousands-of-miles-away-might-watch-your-medical-exam-with-google-glass/","disqusTitle":"To Lift EHR Burden, Doctors Live-Stream Patient Exams to Remote Scribes","source":"Future of You","path":"/futureofyou/434787/why-someone-thousands-of-miles-away-might-watch-your-medical-exam-with-google-glass","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>The familiar phrase, “The doctor will see you now,” is not what it used to be.\u003c/p>\n\u003cp>That's because during most exams, physicians are spending a good chunk of time not looking at the patient, but at the patient's electronic health record on a computer screen.\u003c/p>\n\u003caside class=\"pullquote alignright\">'We have invested a lot of time to train physicians, so why not have them use their expertise in the most efficient way possible?'\u003c/aside>\n\u003cp>A 2016 \u003ca href=\"http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties\" target=\"_blank\" rel=\"noopener noreferrer\"> study\u003c/a> in the \u003cem>Annals of Internal Medicine\u003c/em> found that physicians spent 37 percent of their time on\u003cstrong> \u003c/strong>a computer during exams.\u003c/p>\n\u003cp>The situation can be frustrating for patients, who don't think they are getting the doctor's full attention.\u003c/p>\n\u003cp>\"That most fundamental aspect of human communication, which is eye contact, now is being robbed from the medical encounter because of the electronic health record,\" says Dr. Lloyd Minor, dean of Stanford's medical school.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>While acknowledging the benefits of EHRs, which are meant to improve patient care by providing an easily accessible health history, physicians have also railed against the heavy amount of data entry they require. Physicians spend an estimated one to two hours after work completing EHRs and other \"desktop medicine\" requirements, according to the study in \u003cem>Annals of Internal Medicine.\u003c/em>\u003c/p>\n\u003cp>But now Dr. Albert Chan, the chief of digital patient experience for the Sutter Health Network, thinks he has a solution for the burden of EHRs. Chan uses \u003ca href=\"https://www.x.company/glass/\" target=\"_blank\" rel=\"noopener noreferrer\">Google Glass\u003c/a>, with its tiny camera mounted on a device worn like eyeglasses, to stream audio and video of the patient to an offsite medical scribe. The scribe sees and hears what the doctor does, writing the notes that go into the electronic health record. This frees up the physician to give the patient her full attention. Doctors can communicate with their note-takers through a headset, asking them to retrieve test results and other data. The scribe responds via text message, which the physician sees in the Glass lens.\u003c/p>\n\u003caside class=\"pullquote alignright\">'You’re just adding more layers of cost and people to assist in the exam room.'\u003c/aside>\n\u003cp>“For patients, it’s better care because the doctors focus on them, and the doctors spend more time with them,\" Chan says. He says that because the doctor’s attention is not divided between the computer and the patient, records of the visit are more accurate.\u003c/p>\n\u003cp>The system is provided by a company called Augmedix, of which Sutter Health is an investor.\u003c/p>\n\u003cp>Currently about 100 Sutter doctors are using the system. After first deploying it among physicians in internal medicine, Sutter is now expanding it for use by specialists like dermatologists, podiatrists and orthopedists across its Northern California network.\u003c/p>\n\u003cp>“I mean, we have invested a lot of time to train physicians, so why not have them use their expertise in the most efficient way possible?” says Chan.\u003c/p>\n\u003cp>\u003cstrong>Encounter at Dolores Park\u003c/strong>\u003c/p>\n\u003cp>Augmedix was founded in 2012, by Ian Shakil and Pelu Tran. Shakil, who is the CEO, says he got the idea after a chance encounter at San Francisco's Dolores Park with some Google employees who were working on Glass. \"They had Glass in their backpacks. And they let us try it on,\" he says.\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>After the Google crew explained the product was intended for consumers, \"I got into a big argument with the group that this was really meant for doctors.\" (Glass was a notorious bust with the public, but is \u003ca href=\"https://www.wired.com/story/google-glass-2-is-here/\" target=\"_blank\" rel=\"noopener noreferrer\">now hitting its stride as a workplace tool.\u003c/a>)\u003c/p>\n\u003cp>Shakil, who knew from media reports and his own encounters with physicians that they were beleaguered with documentation requirements, says he became obsessed with the idea of using Glass as a solution. \"I couldn't sleep; I couldn't stop talking about it. I literally quit my job.\"\u003c/p>\n\u003cp>He then reeled in his friend Tran, who dropped out of his fourth year at medical school, and the two formed the company. Shakil says more than 1,000 doctors are currently using Augmedix across the U.S. , with the largest deployment by Sutter.\u003c/p>\n\u003cp>Besides Sutter, investors include health services company McKesson and Dignity Health network.\u003c/p>\n\u003cp>Sutter's Dr. Chan says the scribes provide a number of benefits, including reminding physicians to address issues they might otherwise miss.\u003c/p>\n\u003cp>“If you have shoulder pain and chest pain, for instance, well, if I forget to address the shoulder pain during the exam, I can get a subtle hint from the transcriptionist -- ‘Hey, you may want to address the shoulder pain, too.’ ”\u003c/p>\n\u003cp>Because doctors use shorthand when entering information in an EHR, Chan says, they often have to go back hours later and fill in the gaps; that isn't necessary when a third party is taking the notes in real-time.\u003c/p>\n\u003cp>\u003cstrong>'Oh, I Can See My Kid's Soccer Game'\u003c/strong>\u003c/p>\n\u003cp>About two-thirds of Augmedix's note-takers are located overseas, in India, the Dominican Republic and Sri Lanka, says CEO Shakil. But Adeeba Hasan, a full-time scribe for the company, works out of headquarters in San Francisco. Hasan says she's able to take 80 percent of the EHR workload off a doctor's hands. \"My doctors are able to leave and get home about two or three hours early,\" Hasan says. \"They definitely thank for me for little things like, 'Oh, I can see my kids' soccer game.' \"\u003c/p>\n\u003cp>She has scribed for 20 doctors, whose predominant perspective, she says, is that while EHRs are important, they don't require a medical degree to complete. She herself is applying to medical school and finds the experience valuable. \"I'm learning all about different medications and illnesses and how you talk to patients,\" she says.\u003c/p>\n\u003cp>\u003cstrong>A Doubter\u003c/strong>\u003c/p>\n\u003cp>So is this the future of medicine as we know it?\u003c/p>\n\u003cp>“Oh my God, I hope not,” says David Lansky, executive director of the Pacific Business Group on Health, a nonprofit consortium of private companies and public agencies working toward greater health care affordability and quality.\u003c/p>\n\u003cp>The Augmedix service generally ranges from $1,500 to $3,500 per physician, per month, according to Shakil. Lansky says fixing the dysfunctional health care system requires putting the brakes on runaway costs, and using expensive scribes does just the opposite.\u003c/p>\n\u003cp>“You’re just adding more layers of cost and people to assist in the exam room,” Lansky says.\u003c/p>\n\u003cp>He thinks the solution to the burden of EHRs is to lessen reporting requirements, from quality measures to insurance coding to language intended to fend off lawsuits\u003cb>.\u003c/b>\u003c/p>\n\u003cp>“The real problem is that administrative requirements are uncoordinated and useless,\" Lansky says. \"I mean, no one’s even looking at the quality measures physicians are required to key in.\"\u003c/p>\n\u003cp>“The two paths we want to pursue are to reduce reporting and improve EHR function. If everything’s in front of you, you can use your face time [with the patient] to really \u003cem>do\u003c/em> face time.”\u003c/p>\n\u003cp>\u003cstrong>What About the Creepiness Factor?\u003c/strong>\u003c/p>\n\u003cp>Might some patients, especially women, not take too kindly to having something as intimate as a medical exam observed by someone they don't know and can't see?\u003c/p>\n\u003cp>\"To be honest\u003cstrong>, \u003c/strong>\u003cspan class=\"s1\">when we first founded the business, we had no idea if this issue was going to be a show-stopper or not a big deal,\" says Shakil. \"We’ve since grown and we’ve learned that it’ s not actually a big deal.\" \u003c/span>\u003c/p>\n\u003cp>He says only 2 percent of patients have opted out so far, a rate that remains steady across all demographics, including sex.\u003c/p>\n\u003cp>Shakil says the audio-video stream is encrypted, so hacking is not an issue. \"We've penetration-tested it, and it's Fort Knox, basically.\" The scribes sit in what he calls an \"ultra-secure environment,\" with nothing in their pockets, video monitoring, and computers that can only run the company's application.\u003c/p>\n\u003cp>The doctor can also temporarily switch off the Glass feed by swiping or verbal command if there's something occurring the patient doesn't want transmitted. The light on the device changes color to indicate its no longer active, which the patient can see.\u003c/p>\n\u003cp>Interestingly enough, there is one small sub-group of patients who are opting out at a slightly greater rate.\u003c/p>\n\u003cp>\"It's a little bit higher around the Google campus than anywhere in the country,\" Shakil says.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Make of that what you will.\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/434787/why-someone-thousands-of-miles-away-might-watch-your-medical-exam-with-google-glass","authors":["8656","80"],"categories":["futureofyou_452","futureofyou_1062","futureofyou_1","futureofyou_73"],"tags":["futureofyou_1338","futureofyou_190","futureofyou_1336","futureofyou_794","futureofyou_1275","futureofyou_226"],"featImg":"futureofyou_434987","label":"source_futureofyou_434787"},"futureofyou_420143":{"type":"posts","id":"futureofyou_420143","meta":{"index":"posts_1591205157","site":"futureofyou","id":"420143","score":null,"sort":[1500393631000]},"guestAuthors":[],"slug":"hold-on-your-doctor-is-typing","title":"Doctors: Electronic Health Records Hurting Relationship With Patients","publishDate":1500393631,"format":"standard","headTitle":"KQED Future of You | KQED Science","labelTerm":{},"content":"\u003cp>Dr. Lloyd Minor is frustrated. As dean of Stanford University Medical School, he says he can handle the constant cascade of large-scale challenges that come with his job. But what flummoxes him — drives him crazy, in fact — is something that occurs on a much smaller scale every time he examines someone in his clinical practice.\u003c/p>\n\u003cp>Minor cannot get the electronic health record, which provides a medical history of each patient, to work the way he wants. So he spends too much time wrestling with the computer and not enough directly communicating with his patient.\u003c/p>\n\u003caside class=\"pullquote alignright\">'There is nothing more frustrating to a patient than talking to their doctor, wanting advice, and that provider is typing away and looking at a computer screen instead of the patient.' \u003ccite>Stanford medical school Dean Lloyd Minor\u003c/cite>\u003c/aside>\n\u003cp>“There is nothing more frustrating to a patient than talking to their doctor, wanting advice, and that provider is typing away and looking at a computer screen instead of the patient,\" Minor says. \"That most fundamental aspect of human communication, which is eye contact, now is being robbed from the medical encounter because of the electronic health record.”\u003c/p>\n\u003cp>He says EHRs now function primarily as documentation for billing and quality reporting rather than as an aid to doctors. Given their cumbersome nature, the EHR, long touted as a way to dramatically improve patient care, often does just the opposite, Minor believes.\u003c/p>\n\u003cp>“As a provider, you’re thinking about what do I need to document, or how do I navigate the EHR system, not how do I assimilate this information to provide the best care advice to the patient,\" he says. \"You’re thinking about the mechanics of the documentation, rather than the implications of the symptoms and findings.”\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>\u003cstrong>Data Entry or Medicine?\u003c/strong>\u003c/p>\n\u003cp>Many physicians are fed up with the amount of documentation required in EHRs. Many feel they spend more time as data-entry clerks than as doctors.\u003c/p>\n\u003cp>[contextly_sidebar id=\"iCL76xAqQztIVtwiKb3Jdka9M3FawwGC\"]Studies bear that out. Only 27 percent of a doctor’s time is spent with patients — and nearly half is spent on EHR and desk work, according to a \u003ca href=\"http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties\">2016 study\u003c/a> published in \u003cem>Annals of Internal Medicine\u003c/em>. The study looked at physicians in family practice, internal medicine, cardiology and orthopedics. A smaller\u003ca href=\"http://content.healthaffairs.org/content/36/4/655.abstract\" target=\"_blank\" rel=\"noopener noreferrer\"> study\u003c/a> published in April by \u003cem>Health Affairs, \u003c/em>focusing on primary care physicians, also found about a 50-50 split in direct patient care time versus desktop medicine.\u003c/p>\n\u003cp>When doctors do spend time in the exam room with patients, they spent 37 percent of that time looking at the computer, the 2016 study estimated.\u003c/p>\n\u003cp>It's not just recording the patient's medical information that takes up time, according to Dr. Albert Chan, a family practice physician and the chief of digital patient experience for the Sutter Health Network. Doctors now need to report a series of quality measurements, provide proper insurance coding, and introduce more legalistic wording into the EHR to prevent lawsuits, he says.\u003c/p>\n\u003cp>There’s so much required paperwork and documentation now that primary care physicians spend an estimated one to two hours every night after work finishing up their data entry on EHRs, the study in \u003cem>Annals of Internal Medicine\u003c/em> found.\u003c/p>\n\u003cp>In the business, that’s called \"pajama time.\" In the real world, it's called one reason for burnout. Fifty-four \u003ca href=\"http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract\">percent of physicians\u003c/a> reported at least one symptom of burnout, according to a recent Mayo Clinic study. A separate Mayo study found that a higher risk of burnout was \u003ca href=\"http://www.mayoclinicproceedings.org/article/S0025-6196(16)30215-4/abstract\">linked\u003c/a> to frustrations with the data-entry workload of EHRs.\u003c/p>\n\u003cp>\u003cstrong>A Powerful Tool\u003c/strong>\u003c/p>\n\u003cp>When the Affordable Care Act and the 2009 \u003ca href=\"https://www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/index.html\">HITECH Act\u003c/a> required electronic health records to be incorporated into medical practices, Dr. Chan says, many medical groups and physicians rushed to install EHR systems. That means the search function may not work well, or the system may require multiple keystrokes and screens to accomplish common tasks.\u003c/p>\n\u003cp>(Eric Helsher, vice president of client success at Epic, one of the leading EHR providers, responded that customer feedback \"drives our continuous development, with the aim of making the software a joy to use, helping them get value from their data, and facilitating collaboration across the Epic community.\")\u003c/p>\n\u003caside class=\"pullquote alignright\">'I remember back in the old days of paper medical records … not being able to find a patient’s chart was just maddening. We don’t have that anymore.'\u003ccite>Dr. Albert Chan\u003c/cite>\u003c/aside>\n\u003cp>But, Chan says, as flawed as the EHR is, it would be wise not to throw the baby out with the bathwater.\u003c/p>\n\u003cp>“It’s important to note that the EHR is an incredibly powerful tool,” he says. “There are tremendous things you can do with the EHR. You can automatically alert patients about their conditions, for example; you can personalize their care. The lesson I’ve learned is that the EHR requires work to make it work.”\u003c/p>\n\u003cp>Chan says he would never want to go back to the paper-only era.\u003c/p>\n\u003cp>“I remember back in the old days of paper medical records ... not being able to find a patient’s chart was just maddening. We don’t have that anymore.\"\u003c/p>\n\u003cp>\u003cstrong>The Interoperability Problem\u003c/strong>\u003c/p>\n\u003cp>Current design problems can be corrected over time by EHR system vendors, Chan says, and he expects the furor over EHRs to dissipate as annoying and time-consuming glitches are altered.\u003c/p>\n\u003cp>One of the big complaints doctors have had is the lack of interoperability between EHR systems, so that hospitals, medical groups, insurers and physicians can't easily share patient data with each other. In the San Francisco Bay Area, some sharing is now starting to occur among institutions like Sutter Health, Kaiser, UCSF and Stanford that all that use the EHR system Epic.\u003c/p>\n\u003cp>“We’re starting to see fruits of our labor to connect data,” Chan says.\u003c/p>\n\u003cp>But that may be a glass-half-full view, according to Will Ross, a project manager at Redwood MedNet, a nonprofit health information exchange based in Ukiah. Ross has been working on trying to improve the interoperability of EHRs for two decades, and says the progress has been plodding, to say the least.\u003c/p>\n\u003cp>Ross says EHRs took a turn for the worse after Congress tried to get physicians to prove they were meaningfully using them in the HITECH Act of 2009. Those rules, which he calls arbitrary, made the whole process much more complex and time-consuming.\u003c/p>\n\u003cp>\u003cspan style=\"color: #2b2b2b\">“That transformed all of this into busy work and nonsense,” Ross says. \u003c/span>\u003c/p>\n\u003cp>The obvious solution is for vendors to improve their products, he says. But that’s easier proposed than accomplished.\u003c/p>\n\u003cp>“A lot of the EHRs are cash cows to their owners,” Ross says. “They make their money on installing them, not changing them.”\u003c/p>\n\u003cp>Even if the complex problems of interoperability and ease of use were magically solved today, physicians would still be overloaded by reporting requirements, Ross says.\u003c/p>\n\u003cp>“Documentation is still there, so blaming the computer for what insurers and the government are requiring you to do is misplacing the blame.\"\u003c/p>\n\u003cp>Large organizations such as Kaiser and Sutter Health have tackled some of the ease-of-use problems of the EHR, according to David Lansky, executive director of the Pacific Business Group on Health, a nonprofit consortium of private businesses and public agencies. That’s not so easy for smaller practices to do.\u003c/p>\n\u003cp>“In big medical groups, the burden on the individual doctor using EHR is lower already, it’s easier,” Lansky says. “But small-group practices and individuals have the same administrative burden as the large-group practices.\"\u003c/p>\n\u003cp>Lansky’s organization is encouraging smaller groups to join provider contracting networks — niche companies that will help them track patients, install reminder systems, streamline quality reporting and connect with health information exchanges — so smaller practices are not trying to solve the problem themselves.\u003c/p>\n\u003cp class=\"p1\">He says the idea is to get doctors to use their skills and training properly. “We have this cult of the physician, and we pay a lot of money to train them,” Lansky says, “yet they’re being asked to do work others can do very well.”\u003c/p>\n\u003cp>That rings true for Stanford medical school's Dean Minor. He’s sick of scrolling down page by page; sick of checking off a million little boxes. All the time spent on medical documentation cuts down on physician efficiency, he says.\u003c/p>\n\u003cp>If doctors are working so many extra hours entering data, they’re likely to cut down on their patient load to make up for it. That means they make less money, and the quality of patient visits continues to decline.\u003c/p>\n\u003cp>“It negatively impacts patient care, that’s the main thing,” he says.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>\u003cem>This post had been edited.\u003c/em>\u003c/p>\n\n","blocks":[],"excerpt":"Electronic health records were supposed to make life easier for physicians and help improve patient care. But clunky design and the mountain of new documentation requirements have contributed to doctor frustration and burnout.","status":"publish","parent":0,"modified":1500585788,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":39,"wordCount":1527},"headData":{"title":"Doctors: Electronic Health Records Hurting Relationship With Patients | KQED","description":"Electronic health records were supposed to make life easier for physicians and help improve patient care. But clunky design and the mountain of new documentation requirements have contributed to doctor frustration and burnout.","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Doctors: Electronic Health Records Hurting Relationship With Patients","datePublished":"2017-07-18T16:00:31.000Z","dateModified":"2017-07-20T21:23:08.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"420143 https://ww2.kqed.org/futureofyou/?p=420143","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/07/18/hold-on-your-doctor-is-typing/","disqusTitle":"Doctors: Electronic Health Records Hurting Relationship With Patients","source":"KQED Future of You","nprByline":"David Gorn\u003cbr />Future of You","path":"/futureofyou/420143/hold-on-your-doctor-is-typing","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>Dr. Lloyd Minor is frustrated. As dean of Stanford University Medical School, he says he can handle the constant cascade of large-scale challenges that come with his job. But what flummoxes him — drives him crazy, in fact — is something that occurs on a much smaller scale every time he examines someone in his clinical practice.\u003c/p>\n\u003cp>Minor cannot get the electronic health record, which provides a medical history of each patient, to work the way he wants. So he spends too much time wrestling with the computer and not enough directly communicating with his patient.\u003c/p>\n\u003caside class=\"pullquote alignright\">'There is nothing more frustrating to a patient than talking to their doctor, wanting advice, and that provider is typing away and looking at a computer screen instead of the patient.' \u003ccite>Stanford medical school Dean Lloyd Minor\u003c/cite>\u003c/aside>\n\u003cp>“There is nothing more frustrating to a patient than talking to their doctor, wanting advice, and that provider is typing away and looking at a computer screen instead of the patient,\" Minor says. \"That most fundamental aspect of human communication, which is eye contact, now is being robbed from the medical encounter because of the electronic health record.”\u003c/p>\n\u003cp>He says EHRs now function primarily as documentation for billing and quality reporting rather than as an aid to doctors. Given their cumbersome nature, the EHR, long touted as a way to dramatically improve patient care, often does just the opposite, Minor believes.\u003c/p>\n\u003cp>“As a provider, you’re thinking about what do I need to document, or how do I navigate the EHR system, not how do I assimilate this information to provide the best care advice to the patient,\" he says. \"You’re thinking about the mechanics of the documentation, rather than the implications of the symptoms and findings.”\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\u003cstrong>Data Entry or Medicine?\u003c/strong>\u003c/p>\n\u003cp>Many physicians are fed up with the amount of documentation required in EHRs. Many feel they spend more time as data-entry clerks than as doctors.\u003c/p>\n\u003cp>\u003c/p>\u003cp>\u003c/p>\u003cp>Studies bear that out. Only 27 percent of a doctor’s time is spent with patients — and nearly half is spent on EHR and desk work, according to a \u003ca href=\"http://annals.org/aim/article/2546704/allocation-physician-time-ambulatory-practice-time-motion-study-4-specialties\">2016 study\u003c/a> published in \u003cem>Annals of Internal Medicine\u003c/em>. The study looked at physicians in family practice, internal medicine, cardiology and orthopedics. A smaller\u003ca href=\"http://content.healthaffairs.org/content/36/4/655.abstract\" target=\"_blank\" rel=\"noopener noreferrer\"> study\u003c/a> published in April by \u003cem>Health Affairs, \u003c/em>focusing on primary care physicians, also found about a 50-50 split in direct patient care time versus desktop medicine.\u003c/p>\n\u003cp>When doctors do spend time in the exam room with patients, they spent 37 percent of that time looking at the computer, the 2016 study estimated.\u003c/p>\n\u003cp>It's not just recording the patient's medical information that takes up time, according to Dr. Albert Chan, a family practice physician and the chief of digital patient experience for the Sutter Health Network. Doctors now need to report a series of quality measurements, provide proper insurance coding, and introduce more legalistic wording into the EHR to prevent lawsuits, he says.\u003c/p>\n\u003cp>There’s so much required paperwork and documentation now that primary care physicians spend an estimated one to two hours every night after work finishing up their data entry on EHRs, the study in \u003cem>Annals of Internal Medicine\u003c/em> found.\u003c/p>\n\u003cp>In the business, that’s called \"pajama time.\" In the real world, it's called one reason for burnout. Fifty-four \u003ca href=\"http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract\">percent of physicians\u003c/a> reported at least one symptom of burnout, according to a recent Mayo Clinic study. A separate Mayo study found that a higher risk of burnout was \u003ca href=\"http://www.mayoclinicproceedings.org/article/S0025-6196(16)30215-4/abstract\">linked\u003c/a> to frustrations with the data-entry workload of EHRs.\u003c/p>\n\u003cp>\u003cstrong>A Powerful Tool\u003c/strong>\u003c/p>\n\u003cp>When the Affordable Care Act and the 2009 \u003ca href=\"https://www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/index.html\">HITECH Act\u003c/a> required electronic health records to be incorporated into medical practices, Dr. Chan says, many medical groups and physicians rushed to install EHR systems. That means the search function may not work well, or the system may require multiple keystrokes and screens to accomplish common tasks.\u003c/p>\n\u003cp>(Eric Helsher, vice president of client success at Epic, one of the leading EHR providers, responded that customer feedback \"drives our continuous development, with the aim of making the software a joy to use, helping them get value from their data, and facilitating collaboration across the Epic community.\")\u003c/p>\n\u003caside class=\"pullquote alignright\">'I remember back in the old days of paper medical records … not being able to find a patient’s chart was just maddening. We don’t have that anymore.'\u003ccite>Dr. Albert Chan\u003c/cite>\u003c/aside>\n\u003cp>But, Chan says, as flawed as the EHR is, it would be wise not to throw the baby out with the bathwater.\u003c/p>\n\u003cp>“It’s important to note that the EHR is an incredibly powerful tool,” he says. “There are tremendous things you can do with the EHR. You can automatically alert patients about their conditions, for example; you can personalize their care. The lesson I’ve learned is that the EHR requires work to make it work.”\u003c/p>\n\u003cp>Chan says he would never want to go back to the paper-only era.\u003c/p>\n\u003cp>“I remember back in the old days of paper medical records ... not being able to find a patient’s chart was just maddening. We don’t have that anymore.\"\u003c/p>\n\u003cp>\u003cstrong>The Interoperability Problem\u003c/strong>\u003c/p>\n\u003cp>Current design problems can be corrected over time by EHR system vendors, Chan says, and he expects the furor over EHRs to dissipate as annoying and time-consuming glitches are altered.\u003c/p>\n\u003cp>One of the big complaints doctors have had is the lack of interoperability between EHR systems, so that hospitals, medical groups, insurers and physicians can't easily share patient data with each other. In the San Francisco Bay Area, some sharing is now starting to occur among institutions like Sutter Health, Kaiser, UCSF and Stanford that all that use the EHR system Epic.\u003c/p>\n\u003cp>“We’re starting to see fruits of our labor to connect data,” Chan says.\u003c/p>\n\u003cp>But that may be a glass-half-full view, according to Will Ross, a project manager at Redwood MedNet, a nonprofit health information exchange based in Ukiah. Ross has been working on trying to improve the interoperability of EHRs for two decades, and says the progress has been plodding, to say the least.\u003c/p>\n\u003cp>Ross says EHRs took a turn for the worse after Congress tried to get physicians to prove they were meaningfully using them in the HITECH Act of 2009. Those rules, which he calls arbitrary, made the whole process much more complex and time-consuming.\u003c/p>\n\u003cp>\u003cspan style=\"color: #2b2b2b\">“That transformed all of this into busy work and nonsense,” Ross says. \u003c/span>\u003c/p>\n\u003cp>The obvious solution is for vendors to improve their products, he says. But that’s easier proposed than accomplished.\u003c/p>\n\u003cp>“A lot of the EHRs are cash cows to their owners,” Ross says. “They make their money on installing them, not changing them.”\u003c/p>\n\u003cp>Even if the complex problems of interoperability and ease of use were magically solved today, physicians would still be overloaded by reporting requirements, Ross says.\u003c/p>\n\u003cp>“Documentation is still there, so blaming the computer for what insurers and the government are requiring you to do is misplacing the blame.\"\u003c/p>\n\u003cp>Large organizations such as Kaiser and Sutter Health have tackled some of the ease-of-use problems of the EHR, according to David Lansky, executive director of the Pacific Business Group on Health, a nonprofit consortium of private businesses and public agencies. That’s not so easy for smaller practices to do.\u003c/p>\n\u003cp>“In big medical groups, the burden on the individual doctor using EHR is lower already, it’s easier,” Lansky says. “But small-group practices and individuals have the same administrative burden as the large-group practices.\"\u003c/p>\n\u003cp>Lansky’s organization is encouraging smaller groups to join provider contracting networks — niche companies that will help them track patients, install reminder systems, streamline quality reporting and connect with health information exchanges — so smaller practices are not trying to solve the problem themselves.\u003c/p>\n\u003cp class=\"p1\">He says the idea is to get doctors to use their skills and training properly. “We have this cult of the physician, and we pay a lot of money to train them,” Lansky says, “yet they’re being asked to do work others can do very well.”\u003c/p>\n\u003cp>That rings true for Stanford medical school's Dean Minor. He’s sick of scrolling down page by page; sick of checking off a million little boxes. All the time spent on medical documentation cuts down on physician efficiency, he says.\u003c/p>\n\u003cp>If doctors are working so many extra hours entering data, they’re likely to cut down on their patient load to make up for it. That means they make less money, and the quality of patient visits continues to decline.\u003c/p>\n\u003cp>“It negatively impacts patient care, that’s the main thing,” he says.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\u003cem>This post had been edited.\u003c/em>\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/420143/hold-on-your-doctor-is-typing","authors":["byline_futureofyou_420143"],"categories":["futureofyou_452","futureofyou_1","futureofyou_73"],"tags":["futureofyou_190","futureofyou_794","futureofyou_1275","futureofyou_177"],"featImg":"futureofyou_427912","label":"source_futureofyou_420143"},"futureofyou_318702":{"type":"posts","id":"futureofyou_318702","meta":{"index":"posts_1591205157","site":"futureofyou","id":"318702","score":null,"sort":[1484341078000]},"guestAuthors":[],"slug":"electronic-health-records-may-help-customize-medical-treatments","title":"Electronic Health Records May Help Customize Medical Treatments","publishDate":1484341078,"format":"standard","headTitle":"KQED Future of You | KQED Science","labelTerm":{"site":"futureofyou"},"content":"\u003cp>Chances are your doctor has stopped taking notes with pen and paper and moved to computer records. That is supposed to help coordinate your care.\u003c/p>\n\u003cp>Increasingly, researchers are also exploring these computerized records for medical studies and gleaning facts that help individual patients get better care.\u003c/p>\n\u003cp>Computerized medical records are hardly new. Pioneers at one of the nation's first HMOs, Kaiser Permanente, were using electronic medical records \u003ca href=\"http://www.thepermanentejournal.org/issues/2006/summer/4371-the-delivery-of-medical-care.html\">as far back as the 1970s\u003c/a> and saw them as a big part of the future of medicine.\u003c/p>\n\u003cp>\"The part of it that they didn't envision that we're envisioning now, is how proactive a role \u003cem>patients\u003c/em> would be taking,\" says \u003ca href=\"https://www.dor.kaiser.org/external/Tracy_Lieu/\">Dr. Tracy Lieu\u003c/a>, who heads Kaiser's research division in Oakland, Calif.\u003c/p>\n\u003cp>Medical records don't simply store facts about an individual's health. There's a big potential for a database of medical records to be mined to help shape an individual's treatment.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>\"Patients are always saying, don't just give me the averages, tell me what happened to others who look like me and made the same treatment decisions I did,\" Lieu says. \"And tell me not only did they live or die, but tell me what their quality of life was about.\"\u003c/p>\n\u003caside class=\"pullquote alignright\">'Patients are always saying, don't just give me the averages, tell me what happened to others who look like me and made the same treatment decisions I did. And tell me not only did they live or die, but tell me what their quality of life was about.'\u003ccite>Dr. Tracy Lieu, Kaiser Permanente research division\u003c/cite>\u003c/aside>\n\u003cp>Kaiser hasn't put this concept into action, but it's working toward it. Lieu has a prototype of how it could work. She scoots up to a keyboard in her office and types in \"pancreatic cancer.\"\u003c/p>\n\u003cp>That search function pulls up data from Kaiser's long history of treating this disease. She can narrow that search by cancer type, stage, patient's age and treatment options, to look at trends and outcomes.\u003c/p>\n\u003cp>The records also include information about patients' feelings and emotional states based on a nine-question survey that patients routinely fill out. (Individuals are not identified in the database.)\u003c/p>\n\u003cp>That provides a hint about how a person felt before, during and after cancer treatment. But it's not as complete a picture as patients might want as they weigh their options about treatment choices.\u003c/p>\n\u003cp>Unfortunately, getting that level of detail could be a challenge, because it requires much more data than doctors currently collect.\u003c/p>\n\u003cp>\"If you're a patient and someone says, 'Gee, we'd like you to fill out this 30-item survey on a routine basis,' you're going to say 'Why?' \" she says. \"'What will this get me? How will this help my care?' \"\u003c/p>\n\u003cp>Yet that information could be incredibly useful to other patients contemplating treatment decisions.\u003c/p>\n\u003cp>Another piece missing from the Kaiser records is genetic information about patients.\u003c/p>\n\u003cp>Here, the \u003ca href=\"https://www.geisinger.org/\">Geisinger Health System\u003c/a> in Pennsylvania is making strides. It has sunk a lot of money and effort into adding gene scans to electronic medical records. It already has scans for 50,000 patients in its system.\u003c/p>\n\u003cp>Dr. David Ledbetter, the chief scientific officer, says that number is growing fast, toward a goal of more than 125,000 patients — and beyond.\u003c/p>\n\u003cp>\"Even though this is primarily a research project, we're identifying genomic variants that are actually important to people's health and health care today,\" \u003ca href=\"https://webapps.geisinger.org/articles/articles/DavidLedbetterPhDnamedEV4355.html\">Ledbetter\u003c/a> says.\u003c/p>\n\u003cp>Geisinger patient Jody Christ volunteered to get the genetic screen during one of her routine medical visits. Her doctor had been concerned about her high cholesterol and told her to work on getting in shape.\u003c/p>\n\u003cp>\"So I started to ride a bike and 10 minutes in, I would start to get a sensation down my left arm,\" she says.\u003c/p>\n\u003cp>That made the 61-year-old from Elysburg, Pa., uneasy, so she stopped exercising.\u003c/p>\n\u003cp>But last February she got a call from the program that had run the genetic testing. They told her she had inherited a genetic trait called \u003ca href=\"https://medlineplus.gov/ency/article/000392.htm\">familial hypercholesterolemia\u003c/a>, and that was why she had persistently high cholesterol levels. The disorder makes the body unable to remove cholesterol from the blood, making patients more vulnerable to narrowing of the arteries at an early age.\u003c/p>\n\u003cp>That genetic diagnosis led to a series of clinical tests through the spring. Toward the end of April, Christ took a stress test, which suggested serious heart trouble.\u003c/p>\n\u003cp>A few days later, her heart vessels were scanned in the cardiac catheterization lab, \"and by May 5th I was having triple bypass surgery.\"\u003c/p>\n\u003cp>She feels much better today and is grateful that she had volunteered for the genetic test that revealed this serious problem. \"I feel they saved my life,\" Christ says.\u003c/p>\n\u003cp>Genetic testing like this (known as \u003ca href=\"https://www.nisc.nih.gov/docs/FAQ_whole_exome.pdf\">exome sequencing\u003c/a>) is not routine because the tests typically cost a few thousand dollars. But Ledbetter says the prices are falling fast, and this year could even be in the $300 range.\u003c/p>\n\u003cp>\"So we think as the cost comes down it will be possible to sequence all the genes of individual patients, store that information in the electronic medical record, and it will guide and individualize and optimize patient care,\" he says.\u003c/p>\n\u003cp>Doctors don't know how to interpret most of the genetic results. But there are a few genetic variations, like Christ's cholesterol marker, that are clear indications of serious health problems. Ledbetter said easy-to-interpret variants like that have shown up in 3.5 percent of the patients\u003ca href=\"http://science.sciencemag.org/content/354/6319/aaf6814\"> they studied\u003c/a> recently.\u003c/p>\n\u003cp>That means the test doesn't provide actionable information for the vast majority of the people who get it. But \"that 3.5 percent is going to grow,\" Ledbetter says, as scientists learn to identify more genes that are associated with disease, and scientists identify more of those genes in their population. \"I don't know what the final number will be, but it will be in the 5 to 10 percent range.\"\u003c/p>\n\u003cp>The hope, he says, is that it will help reveal the biology of more common forms of cancer and cardiovascular disease, and possibly more complex diseases like obesity and diabetes.\u003c/p>\n\u003cp>Geisinger's experiment, done in partnership with a company called \u003ca href=\"https://www.regeneron.com/genetics-center\">Regeneron\u003c/a>, which funds and performs the gene scans, is an important foray into the new world where genetic data merge with electronic medical records.\u003c/p>\n\u003cp>\"The scientific community has been waiting to see what would happen here,\" says \u003ca href=\"https://medicine.yale.edu/intmed/people/harlan_krumholz.profile\">Dr. Harlan Krumholz\u003c/a>, a professor of medicine at Yale University who researches cardiology and health care.\u003c/p>\n\u003cp>He's excited at the prospect of being able to look at physical symptoms in medical records and then look for genetic variations that could be responsible, but he says that the system is so far not at all robust.\u003c/p>\n\u003cp>\"The quality of data [collected in medical records] is not necessarily research quality,\" Krumholz says.\u003c/p>\n\u003cp>Think of something as basic as the language in these medical records. The word \"shock\" in a medical record could mean different things to different people.\u003c/p>\n\u003cp>\"So I think it would be unfortunate if people felt that all of a sudden we had this remarkable treasure trove. There's a long way to go to move from where we are now to where we need to be,\" he says.\u003c/p>\n\u003cp>The federal government is planning to recruit a million volunteers to expand this approach to research in its Precision Medicine Initiative, which has been rebranded as the \"\u003ca href=\"https://www.nih.gov/research-training/allofus-research-program\">All of Us\u003c/a>\" research program.\u003c/p>\n\u003cp>The Department of Veterans Affairs started a \u003ca href=\"http://www.research.va.gov/mvp/\">similar effort\u003c/a> in 2012. Scientists there have gathered a huge amount of data, which they are \u003ca href=\"http://www.jclinepi.com/article/S0895-4356(15)00444-8/abstract\">now starting to explore\u003c/a>.\u003c/p>\n\u003cp>But medicine is not yet at home in the world of big data, Krumholz says.\u003c/p>\n\u003cp>\"Medicine's got to catch up, and medicine's got to understand how best to take advantage of all the information that's been generated every day,\" he says.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>The early experiences, at Kaiser, Geisinger and elsewhere, are helping find the path forward.\u003c/p>\n\u003cdiv class=\"fullattribution\">Copyright 2017 NPR. To see more, visit http://www.npr.org/.\u003cimg src=\"http://www.google-analytics.com/__utm.gif?utmac=UA-5828686-4&utmdt=Electronic+Health+Records+May+Help+Customize+Medical+Treatments&utme=8(APIKey)9(MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004)\">\u003c/div>\n\n","blocks":[],"excerpt":"Most people's doctors put their health information in an electronic health record. Scientists are mining those records for clues to what treatments work best for individuals.","status":"publish","parent":0,"modified":1484321730,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":42,"wordCount":1347},"headData":{"title":"Electronic Health Records May Help Customize Medical Treatments | KQED","description":"Most people's doctors put their health information in an electronic health record. Scientists are mining those records for clues to what treatments work best for individuals.","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Electronic Health Records May Help Customize Medical Treatments","datePublished":"2017-01-13T20:57:58.000Z","dateModified":"2017-01-13T15:35:30.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"318702 http://ww2.kqed.org/futureofyou/?p=318702","disqusUrl":"https://ww2.kqed.org/futureofyou/2017/01/13/electronic-health-records-may-help-customize-medical-treatments/","disqusTitle":"Electronic Health Records May Help Customize Medical Treatments","nprByline":"Richard Harris\u003c/br>NPR","nprImageAgency":"Maria Fabrizio for NPR","nprStoryId":"508241690","nprApiLink":"http://api.npr.org/query?id=508241690&apiKey=MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004","nprHtmlLink":"http://www.npr.org/sections/health-shots/2017/01/09/508241690/electronic-health-records-may-help-customize-medical-treatments?ft=nprml&f=508241690","nprRetrievedStory":"1","nprPubDate":"Tue, 10 Jan 2017 16:44:00 -0500","nprStoryDate":"Mon, 09 Jan 2017 04:59:00 -0500","nprLastModifiedDate":"Tue, 10 Jan 2017 16:44:30 -0500","nprAudio":"https://ondemand.npr.org/anon.npr-mp3/npr/me/2017/01/20170109_me_electronic_health_records_may_help_customize_medical_treatments.mp3?orgId=1&topicId=1066&d=389&p=3&story=508241690&t=progseg&e=508902772&seg=3&ft=nprml&f=508241690","nprAudioM3u":"http://api.npr.org/m3u/1508902980-751a81.m3u?orgId=1&topicId=1066&d=389&p=3&story=508241690&t=progseg&e=508902772&seg=3&ft=nprml&f=508241690","path":"/futureofyou/318702/electronic-health-records-may-help-customize-medical-treatments","audioUrl":"https://ondemand.npr.org/anon.npr-mp3/npr/me/2017/01/20170109_me_electronic_health_records_may_help_customize_medical_treatments.mp3?orgId=1&topicId=1066&d=389&p=3&story=508241690&t=progseg&e=508902772&seg=3&ft=nprml&f=508241690","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>Chances are your doctor has stopped taking notes with pen and paper and moved to computer records. That is supposed to help coordinate your care.\u003c/p>\n\u003cp>Increasingly, researchers are also exploring these computerized records for medical studies and gleaning facts that help individual patients get better care.\u003c/p>\n\u003cp>Computerized medical records are hardly new. Pioneers at one of the nation's first HMOs, Kaiser Permanente, were using electronic medical records \u003ca href=\"http://www.thepermanentejournal.org/issues/2006/summer/4371-the-delivery-of-medical-care.html\">as far back as the 1970s\u003c/a> and saw them as a big part of the future of medicine.\u003c/p>\n\u003cp>\"The part of it that they didn't envision that we're envisioning now, is how proactive a role \u003cem>patients\u003c/em> would be taking,\" says \u003ca href=\"https://www.dor.kaiser.org/external/Tracy_Lieu/\">Dr. Tracy Lieu\u003c/a>, who heads Kaiser's research division in Oakland, Calif.\u003c/p>\n\u003cp>Medical records don't simply store facts about an individual's health. There's a big potential for a database of medical records to be mined to help shape an individual's treatment.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>\"Patients are always saying, don't just give me the averages, tell me what happened to others who look like me and made the same treatment decisions I did,\" Lieu says. \"And tell me not only did they live or die, but tell me what their quality of life was about.\"\u003c/p>\n\u003caside class=\"pullquote alignright\">'Patients are always saying, don't just give me the averages, tell me what happened to others who look like me and made the same treatment decisions I did. And tell me not only did they live or die, but tell me what their quality of life was about.'\u003ccite>Dr. Tracy Lieu, Kaiser Permanente research division\u003c/cite>\u003c/aside>\n\u003cp>Kaiser hasn't put this concept into action, but it's working toward it. Lieu has a prototype of how it could work. She scoots up to a keyboard in her office and types in \"pancreatic cancer.\"\u003c/p>\n\u003cp>That search function pulls up data from Kaiser's long history of treating this disease. She can narrow that search by cancer type, stage, patient's age and treatment options, to look at trends and outcomes.\u003c/p>\n\u003cp>The records also include information about patients' feelings and emotional states based on a nine-question survey that patients routinely fill out. (Individuals are not identified in the database.)\u003c/p>\n\u003cp>That provides a hint about how a person felt before, during and after cancer treatment. But it's not as complete a picture as patients might want as they weigh their options about treatment choices.\u003c/p>\n\u003cp>Unfortunately, getting that level of detail could be a challenge, because it requires much more data than doctors currently collect.\u003c/p>\n\u003cp>\"If you're a patient and someone says, 'Gee, we'd like you to fill out this 30-item survey on a routine basis,' you're going to say 'Why?' \" she says. \"'What will this get me? How will this help my care?' \"\u003c/p>\n\u003cp>Yet that information could be incredibly useful to other patients contemplating treatment decisions.\u003c/p>\n\u003cp>Another piece missing from the Kaiser records is genetic information about patients.\u003c/p>\n\u003cp>Here, the \u003ca href=\"https://www.geisinger.org/\">Geisinger Health System\u003c/a> in Pennsylvania is making strides. It has sunk a lot of money and effort into adding gene scans to electronic medical records. It already has scans for 50,000 patients in its system.\u003c/p>\n\u003cp>Dr. David Ledbetter, the chief scientific officer, says that number is growing fast, toward a goal of more than 125,000 patients — and beyond.\u003c/p>\n\u003cp>\"Even though this is primarily a research project, we're identifying genomic variants that are actually important to people's health and health care today,\" \u003ca href=\"https://webapps.geisinger.org/articles/articles/DavidLedbetterPhDnamedEV4355.html\">Ledbetter\u003c/a> says.\u003c/p>\n\u003cp>Geisinger patient Jody Christ volunteered to get the genetic screen during one of her routine medical visits. Her doctor had been concerned about her high cholesterol and told her to work on getting in shape.\u003c/p>\n\u003cp>\"So I started to ride a bike and 10 minutes in, I would start to get a sensation down my left arm,\" she says.\u003c/p>\n\u003cp>That made the 61-year-old from Elysburg, Pa., uneasy, so she stopped exercising.\u003c/p>\n\u003cp>But last February she got a call from the program that had run the genetic testing. They told her she had inherited a genetic trait called \u003ca href=\"https://medlineplus.gov/ency/article/000392.htm\">familial hypercholesterolemia\u003c/a>, and that was why she had persistently high cholesterol levels. The disorder makes the body unable to remove cholesterol from the blood, making patients more vulnerable to narrowing of the arteries at an early age.\u003c/p>\n\u003cp>That genetic diagnosis led to a series of clinical tests through the spring. Toward the end of April, Christ took a stress test, which suggested serious heart trouble.\u003c/p>\n\u003cp>A few days later, her heart vessels were scanned in the cardiac catheterization lab, \"and by May 5th I was having triple bypass surgery.\"\u003c/p>\n\u003cp>She feels much better today and is grateful that she had volunteered for the genetic test that revealed this serious problem. \"I feel they saved my life,\" Christ says.\u003c/p>\n\u003cp>Genetic testing like this (known as \u003ca href=\"https://www.nisc.nih.gov/docs/FAQ_whole_exome.pdf\">exome sequencing\u003c/a>) is not routine because the tests typically cost a few thousand dollars. But Ledbetter says the prices are falling fast, and this year could even be in the $300 range.\u003c/p>\n\u003cp>\"So we think as the cost comes down it will be possible to sequence all the genes of individual patients, store that information in the electronic medical record, and it will guide and individualize and optimize patient care,\" he says.\u003c/p>\n\u003cp>Doctors don't know how to interpret most of the genetic results. But there are a few genetic variations, like Christ's cholesterol marker, that are clear indications of serious health problems. Ledbetter said easy-to-interpret variants like that have shown up in 3.5 percent of the patients\u003ca href=\"http://science.sciencemag.org/content/354/6319/aaf6814\"> they studied\u003c/a> recently.\u003c/p>\n\u003cp>That means the test doesn't provide actionable information for the vast majority of the people who get it. But \"that 3.5 percent is going to grow,\" Ledbetter says, as scientists learn to identify more genes that are associated with disease, and scientists identify more of those genes in their population. \"I don't know what the final number will be, but it will be in the 5 to 10 percent range.\"\u003c/p>\n\u003cp>The hope, he says, is that it will help reveal the biology of more common forms of cancer and cardiovascular disease, and possibly more complex diseases like obesity and diabetes.\u003c/p>\n\u003cp>Geisinger's experiment, done in partnership with a company called \u003ca href=\"https://www.regeneron.com/genetics-center\">Regeneron\u003c/a>, which funds and performs the gene scans, is an important foray into the new world where genetic data merge with electronic medical records.\u003c/p>\n\u003cp>\"The scientific community has been waiting to see what would happen here,\" says \u003ca href=\"https://medicine.yale.edu/intmed/people/harlan_krumholz.profile\">Dr. Harlan Krumholz\u003c/a>, a professor of medicine at Yale University who researches cardiology and health care.\u003c/p>\n\u003cp>He's excited at the prospect of being able to look at physical symptoms in medical records and then look for genetic variations that could be responsible, but he says that the system is so far not at all robust.\u003c/p>\n\u003cp>\"The quality of data [collected in medical records] is not necessarily research quality,\" Krumholz says.\u003c/p>\n\u003cp>Think of something as basic as the language in these medical records. The word \"shock\" in a medical record could mean different things to different people.\u003c/p>\n\u003cp>\"So I think it would be unfortunate if people felt that all of a sudden we had this remarkable treasure trove. There's a long way to go to move from where we are now to where we need to be,\" he says.\u003c/p>\n\u003cp>The federal government is planning to recruit a million volunteers to expand this approach to research in its Precision Medicine Initiative, which has been rebranded as the \"\u003ca href=\"https://www.nih.gov/research-training/allofus-research-program\">All of Us\u003c/a>\" research program.\u003c/p>\n\u003cp>The Department of Veterans Affairs started a \u003ca href=\"http://www.research.va.gov/mvp/\">similar effort\u003c/a> in 2012. Scientists there have gathered a huge amount of data, which they are \u003ca href=\"http://www.jclinepi.com/article/S0895-4356(15)00444-8/abstract\">now starting to explore\u003c/a>.\u003c/p>\n\u003cp>But medicine is not yet at home in the world of big data, Krumholz says.\u003c/p>\n\u003cp>\"Medicine's got to catch up, and medicine's got to understand how best to take advantage of all the information that's been generated every day,\" he says.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>The early experiences, at Kaiser, Geisinger and elsewhere, are helping find the path forward.\u003c/p>\n\u003cdiv class=\"fullattribution\">Copyright 2017 NPR. To see more, visit http://www.npr.org/.\u003cimg src=\"http://www.google-analytics.com/__utm.gif?utmac=UA-5828686-4&utmdt=Electronic+Health+Records+May+Help+Customize+Medical+Treatments&utme=8(APIKey)9(MDAxOTAwOTE4MDEyMTkxMDAzNjczZDljZA004)\">\u003c/div>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/318702/electronic-health-records-may-help-customize-medical-treatments","authors":["byline_futureofyou_318702"],"categories":["futureofyou_1"],"tags":["futureofyou_794","futureofyou_268"],"featImg":"futureofyou_318703","label":"futureofyou"},"futureofyou_133530":{"type":"posts","id":"futureofyou_133530","meta":{"index":"posts_1591205157","site":"futureofyou","id":"133530","score":null,"sort":[1458755523000]},"guestAuthors":[],"slug":"electronic-records-mismatch-can-stymie-end-of-life-plans","title":"Electronic Records Mismatch Can Stymie End-Of-Life Plans","publishDate":1458755523,"format":"standard","headTitle":"Future of You | KQED Future of You | KQED Science","labelTerm":{"term":54,"site":"futureofyou"},"content":"\u003cp>In a perfect world, patients with advance directives would be confident that their doctors and nurses — no matter where they receive care — could know in a split second their end-of-life wishes.\u003c/p>\n\u003cp>But this ideal is still in the distance. Patients’ documents often go missing in maze-like files or are rendered unreadable by incompatible software. And this risk continues even as health systems and physician practices adopt new electronic health records. So advocates and policymakers are pushing for a fix.\u003c/p>\n\u003cp>The problem isn’t new, experts noted. Advance directives were lost during the era of paper records, too. But, so far, digital efforts have fallen short.\u003c/p>\n\u003cp>“When these systems don’t work — and currently, they don’t work well enough — then that has a huge negative feedback on doctors and patients and families,” said Dr. Lachlan Forrow, director of the ethics and palliative care program at Boston’s Beth Israel Deaconess Medical Center. “Like, why even bother?” Thinking through and writing down end-of-life preferences can be grueling, he added.\u003c/p>\n\u003cp>Still, end-of-life planning has been encouraged by ethicists and experts in recent years, who say it communicates patient choices about medical interventions like being connected to a ventilator or feeding tube, or being resuscitated after heart failure — especially when patients can’t speak for themselves. This January, Medicare began paying doctors to discuss end-of-life wishes with patients, a policy almost 90 percent of Americans support. Meanwhile, according to 2015 figures from the Kaiser Family Foundation, 60 percent of adults older than 65 have such directives. (KHN is an editorially independent program of the foundation.)\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Here’s how difficulties arise. Maybe a patient’s doctor uses one record system and the emergency room another. If the software doesn’t match up, the ER doctors may be unable to tell if the patient has a preference like a “do-not-resuscitate” order.\u003c/p>\n\u003cp>“An individual will fill out an advance directive, but unless they bring a copy with them, the provider will likely not know or see it exists,” said Kim Callinan, chief program officer at Compassion & Choices, a Colorado-based group that advocates for end-of-life care options.\u003c/p>\n\u003cp>Also, older patients, who are increasingly likely to have a directive, often get treatment from varied sources — surgeons, hospitals, nursing homes, primary physicians. That increases the odds of unaligned systems, said Dr. Irene Hamrick, who directs geriatric services in family medicine at the University of Wisconsin-Madison.\u003c/p>\n\u003cp>An additional complication stems from system design. Many systems don’t have a dedicated tab to mark where such information — if it exists — is stored. After doctors and nurses click through various pages, they still don’t know whether they looked in the right place. Time doesn’t always allow this kind of search.\u003c/p>\n\u003cp>“If they’re not able to access the advance directive quickly and easily, they’re honestly likely not to use it,” said Torrie Fields, senior program manager for palliative care at Blue Shield of California. “They’ll end up erring on the side of the most treatment possible.”\u003c/p>\n\u003cp>No one has researched how often this flaw yields unwanted treatment for dying patients. Based on anecdote, it’s “really common,” said Judy Thomas, CEO of the Coalition for Compassionate Care of California, an end-of-life care advocacy group.\u003c/p>\n\u003cp>\u003cstrong>Fixes Proposed\u003c/strong>\u003c/p>\n\u003cp>Changes may lie ahead. Developers of record systems are introducing functions that could make it easier to find and read an advance directive, said Harriet Warshaw, executive director of the Boston-based Conversation Project, which encourages families to discuss end-of-life options. Epic Systems, a Madison, Wisconsin-based company that is among the dominant sellers for electronic health records, has added a tab intended to indicate clearly whether a patient has an advance directive on file. Cerner, based in Missouri, has partnered with a website, MyDirectives. Patients can upload their forms to that website, and doctors can reach it through Cerner.\u003c/p>\n\u003cp>“Advance care planning is an important issue we’re tackling,” said Bob Robke, Cerner’s vice president of interoperability. “To that end, we’ve made recent improvements … that address advance directive documentation.”\u003c/p>\n\u003cp>Cerner, Robke added, is dedicated to helping “overcome [the] barriers to data exchange” between different software systems that can currently block doctors from seeing advance directives.\u003c/p>\n\u003cp>Additional efforts are underway.\u003c/p>\n\u003cp>In Congress, lawmakers have expressed interest in making directives “portable” — that is, easily accessible. Legislation introduced in the Senate by Sen. Mark Warner, D-Virginia, includes provisions that could push health facilities to ensure compatibility across different health records for advance directives. Rep. Earl Blumenauer, D-Oregon, is also working on legislation, he said in an interview.\u003c/p>\n\u003cp>Hospitals and health systems are also making adjustments. The hospital at Oregon Health & Science University, California-based Sharp Hospice and Gunderson Health in Wisconsin are among those that have made in-house software revisions to make advance directives easy to find in electronic health records — for instance having IT teams add tabs on the record’s main page to indicate if a patient has end-of-life planning documents. Representatives of those hospitals said such efforts aren’t the norm, though.\u003c/p>\n\u003cp>Meanwhile, a number of states, including Virginia, Vermont, North Carolina and Arizona, have created online databases for residents to upload and store their advance directives. Recent figures are hard to come by, but in 2007, nine states were counted to have these in place. In these instances, doctors can go online to find a patient’s advance directive on those websites. They’re secured websites, and directives are password protected, requiring special logins from both patients and doctors, but specifics vary from state to state.\u003c/p>\n\u003cp>But there’s debate over how to finance state websites — in North Carolina, for instance, patients pay a $10 one-time fee to upload their advance directive. That can be an easy, low-cost way to maintain a site’s upkeep, but it can also discourage people from doing something they already find unappealing, said Marian Grant, director of policy and professional engagement at the Coalition to Transform Advanced Care and an associate professor at the University of Maryland School of Nursing.\u003c/p>\n\u003cp>These fixes lead to other complications, too. Directories specific to a particular state don’t necessarily accommodate patients who travel regularly between states — for example, a patient who sees one doctor in New Jersey and another in New York. And doctors navigating a cumbersome health record system may not take the additional time to check multiple websites.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>“If you are sick enough and worried about finding your advance directives, it’s a critical situation. We are moving very fast,” said Grant. “We don’t have extra staff to say, ‘She might have an advance directive somewhere — check the top five directories and let me know.’ A busy resident is going to look in one place, and if they don’t find it, move on.”\u003c/p>\n\n","blocks":[],"excerpt":"Even as health systems adopt new electronic health records, advance directives are often rendered unreadable by incompatible software. ","status":"publish","parent":0,"modified":1458755553,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":24,"wordCount":1225},"headData":{"title":"Electronic Records Mismatch Can Stymie End-Of-Life Plans | KQED","description":"Even as health systems adopt new electronic health records, advance directives are often rendered unreadable by incompatible software. ","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Electronic Records Mismatch Can Stymie End-Of-Life Plans","datePublished":"2016-03-23T17:52:03.000Z","dateModified":"2016-03-23T17:52:33.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"133530 http://ww2.kqed.org/futureofyou/?p=133530","disqusUrl":"https://ww2.kqed.org/futureofyou/2016/03/23/electronic-records-mismatch-can-stymie-end-of-life-plans/","disqusTitle":"Electronic Records Mismatch Can Stymie End-Of-Life Plans","nprByline":"Shefali Luthra\u003cbr />\u003ca href=\"http://www.khn.org/\">Kaiser Health News\u003c/a>","path":"/futureofyou/133530/electronic-records-mismatch-can-stymie-end-of-life-plans","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>In a perfect world, patients with advance directives would be confident that their doctors and nurses — no matter where they receive care — could know in a split second their end-of-life wishes.\u003c/p>\n\u003cp>But this ideal is still in the distance. Patients’ documents often go missing in maze-like files or are rendered unreadable by incompatible software. And this risk continues even as health systems and physician practices adopt new electronic health records. So advocates and policymakers are pushing for a fix.\u003c/p>\n\u003cp>The problem isn’t new, experts noted. Advance directives were lost during the era of paper records, too. But, so far, digital efforts have fallen short.\u003c/p>\n\u003cp>“When these systems don’t work — and currently, they don’t work well enough — then that has a huge negative feedback on doctors and patients and families,” said Dr. Lachlan Forrow, director of the ethics and palliative care program at Boston’s Beth Israel Deaconess Medical Center. “Like, why even bother?” Thinking through and writing down end-of-life preferences can be grueling, he added.\u003c/p>\n\u003cp>Still, end-of-life planning has been encouraged by ethicists and experts in recent years, who say it communicates patient choices about medical interventions like being connected to a ventilator or feeding tube, or being resuscitated after heart failure — especially when patients can’t speak for themselves. This January, Medicare began paying doctors to discuss end-of-life wishes with patients, a policy almost 90 percent of Americans support. Meanwhile, according to 2015 figures from the Kaiser Family Foundation, 60 percent of adults older than 65 have such directives. (KHN is an editorially independent program of the foundation.)\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Here’s how difficulties arise. Maybe a patient’s doctor uses one record system and the emergency room another. If the software doesn’t match up, the ER doctors may be unable to tell if the patient has a preference like a “do-not-resuscitate” order.\u003c/p>\n\u003cp>“An individual will fill out an advance directive, but unless they bring a copy with them, the provider will likely not know or see it exists,” said Kim Callinan, chief program officer at Compassion & Choices, a Colorado-based group that advocates for end-of-life care options.\u003c/p>\n\u003cp>Also, older patients, who are increasingly likely to have a directive, often get treatment from varied sources — surgeons, hospitals, nursing homes, primary physicians. That increases the odds of unaligned systems, said Dr. Irene Hamrick, who directs geriatric services in family medicine at the University of Wisconsin-Madison.\u003c/p>\n\u003cp>An additional complication stems from system design. Many systems don’t have a dedicated tab to mark where such information — if it exists — is stored. After doctors and nurses click through various pages, they still don’t know whether they looked in the right place. Time doesn’t always allow this kind of search.\u003c/p>\n\u003cp>“If they’re not able to access the advance directive quickly and easily, they’re honestly likely not to use it,” said Torrie Fields, senior program manager for palliative care at Blue Shield of California. “They’ll end up erring on the side of the most treatment possible.”\u003c/p>\n\u003cp>No one has researched how often this flaw yields unwanted treatment for dying patients. Based on anecdote, it’s “really common,” said Judy Thomas, CEO of the Coalition for Compassionate Care of California, an end-of-life care advocacy group.\u003c/p>\n\u003cp>\u003cstrong>Fixes Proposed\u003c/strong>\u003c/p>\n\u003cp>Changes may lie ahead. Developers of record systems are introducing functions that could make it easier to find and read an advance directive, said Harriet Warshaw, executive director of the Boston-based Conversation Project, which encourages families to discuss end-of-life options. Epic Systems, a Madison, Wisconsin-based company that is among the dominant sellers for electronic health records, has added a tab intended to indicate clearly whether a patient has an advance directive on file. Cerner, based in Missouri, has partnered with a website, MyDirectives. Patients can upload their forms to that website, and doctors can reach it through Cerner.\u003c/p>\n\u003cp>“Advance care planning is an important issue we’re tackling,” said Bob Robke, Cerner’s vice president of interoperability. “To that end, we’ve made recent improvements … that address advance directive documentation.”\u003c/p>\n\u003cp>Cerner, Robke added, is dedicated to helping “overcome [the] barriers to data exchange” between different software systems that can currently block doctors from seeing advance directives.\u003c/p>\n\u003cp>Additional efforts are underway.\u003c/p>\n\u003cp>In Congress, lawmakers have expressed interest in making directives “portable” — that is, easily accessible. Legislation introduced in the Senate by Sen. Mark Warner, D-Virginia, includes provisions that could push health facilities to ensure compatibility across different health records for advance directives. Rep. Earl Blumenauer, D-Oregon, is also working on legislation, he said in an interview.\u003c/p>\n\u003cp>Hospitals and health systems are also making adjustments. The hospital at Oregon Health & Science University, California-based Sharp Hospice and Gunderson Health in Wisconsin are among those that have made in-house software revisions to make advance directives easy to find in electronic health records — for instance having IT teams add tabs on the record’s main page to indicate if a patient has end-of-life planning documents. Representatives of those hospitals said such efforts aren’t the norm, though.\u003c/p>\n\u003cp>Meanwhile, a number of states, including Virginia, Vermont, North Carolina and Arizona, have created online databases for residents to upload and store their advance directives. Recent figures are hard to come by, but in 2007, nine states were counted to have these in place. In these instances, doctors can go online to find a patient’s advance directive on those websites. They’re secured websites, and directives are password protected, requiring special logins from both patients and doctors, but specifics vary from state to state.\u003c/p>\n\u003cp>But there’s debate over how to finance state websites — in North Carolina, for instance, patients pay a $10 one-time fee to upload their advance directive. That can be an easy, low-cost way to maintain a site’s upkeep, but it can also discourage people from doing something they already find unappealing, said Marian Grant, director of policy and professional engagement at the Coalition to Transform Advanced Care and an associate professor at the University of Maryland School of Nursing.\u003c/p>\n\u003cp>These fixes lead to other complications, too. Directories specific to a particular state don’t necessarily accommodate patients who travel regularly between states — for example, a patient who sees one doctor in New Jersey and another in New York. And doctors navigating a cumbersome health record system may not take the additional time to check multiple websites.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>“If you are sick enough and worried about finding your advance directives, it’s a critical situation. We are moving very fast,” said Grant. “We don’t have extra staff to say, ‘She might have an advance directive somewhere — check the top five directories and let me know.’ A busy resident is going to look in one place, and if they don’t find it, move on.”\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/133530/electronic-records-mismatch-can-stymie-end-of-life-plans","authors":["byline_futureofyou_133530"],"programs":["futureofyou_54"],"categories":["futureofyou_452","futureofyou_1"],"tags":["futureofyou_794"],"featImg":"futureofyou_133533","label":"futureofyou_54"},"futureofyou_122266":{"type":"posts","id":"futureofyou_122266","meta":{"index":"posts_1591205157","site":"futureofyou","id":"122266","score":null,"sort":[1457041501000]},"guestAuthors":[],"slug":"electronic-health-records-in-ers-causing-medical-errors","title":"Electronic Health Records in ERs Causing Medical Errors","publishDate":1457041501,"format":"standard","headTitle":"Future of You | KQED Future of You | KQED Science","labelTerm":{"term":54,"site":"futureofyou"},"content":"\u003cp>The mouse slips, and the emergency room doctor clicks on the wrong number, ordering a medication dosage that’s far too large. Elsewhere, in another ER’s electronic health record, a patient’s name isn’t clearly displayed, so the nurse misses it and enters symptoms in the wrong person’s file.\u003c/p>\n\u003caside class=\"pullquote alignright\">The ER’s culture and pace can amplify the risks of human error. Stories of serious near misses are now common lore.\u003c/aside>\n\u003cp>These are easy mistakes to make. As ER doctors and nurses grapple with the transition to digitized record systems, they seem to happen more frequently.\u003c/p>\n\u003cp>“There are new categories of patient safety errors” in emergency rooms that didn’t exist before the push to use electronic record systems, said Raj Ratwani, who researches health care safety and is the scientific director for MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C.\u003c/p>\n\u003cp>Spurred by the 2009 stimulus package and the 2010 health reform law, the federal government has offered hospitals financial incentives to adopt electronic health records that, among other things, will add efficiency and reduce errors by linking physicians’ patient records, and coordinating and tracking how care is delivered across the health system. Hospitals that don’t meet those standards are hit with penalties.\u003c/p>\n\u003cp>But in ERs, where things often happen fast, this push is sometimes setting up a technology mismatch that creates challenges that aren’t necessarily as evident in other parts of the hospital.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Sneaker-clad doctors and nurses rush between patients, often juggling multiple cases. Verbal communication is key. Patients, even after being wheeled in by paramedics, can wait in a triage room for extended periods until a free nurse or physician comes to find out what’s wrong. It’s a different style of medicine, and one that’s often resulted in a distinct workflow.\u003c/p>\n\u003cp>As a result, the electronic record programs in many ERs evolved independently of hospital-wide systems. Since those homegrown, emergency department record systems often aren’t compatible with the newer, comprehensive ones hospitals are buying, they’re being phased out. The new EHR models are in many ways more efficient, but they may require adjustments.\u003c/p>\n\u003cp>The way the systems are set up, it can actually predispose to higher error rates,” said Jesse Pines, who directs the Office for Clinical Practice Innovation at the George Washington University School of Medicine in Washington, D.C.\u003c/p>\n\u003cp>In 2013, Pines, with other members of the American College of Emergency Physicians, wrote a report finding mistakes in the ER — like ordering the wrong medications or, because of confusing computer displays, more easily missing key patient information — were common after the switch to these digital systems.\u003c/p>\n\u003cp>“A growing body of evidence suggests that many errors may be the result of poor design rather than user errors,” the report states. That “can have a profound influence” on patients.\u003c/p>\n\u003cp>“It’s certainly a patient safety concern,” said Jason Shapiro, an associate professor of emergency medicine at Mount Sinai, who chairs ACEP’s informatics committee and co-authored the report.\u003c/p>\n\u003cp>There’s no research measuring how often these errors — like entering care instructions in the wrong patient file or missing instructions altogether — cause actual harm.\u003c/p>\n\u003cp>“We’ve got to figure out how we’re working with our electronic records, to make it part of the workflow,” said Nathan Spell, chief quality officer at Emory Hospital in Atlanta. Even when doctors have learned to use the record systems, missteps still occur.\u003c/p>\n\u003cp>The ER’s culture and pace, for instance, can amplify the risks of human error that stem from an already less user-friendly system. Think of the emergency physician who, reaching the end of a hectic 12-hour shift, looks for the record of a patient he just examined. He types in the man’s last name, clicks and writes medical instructions — not realizing that he’d accidentally pulled up the file of another patient with the same last name and similar age, who was admitted five minutes before.\u003c/p>\n\u003cp>While misidentifying patients in this way was hardly an issue before EHRs, it’s “becoming quite prevalent,” in this more digital era, Ratwani said.\u003c/p>\n\u003cp>Many systems, meanwhile, allow doctors to edit the record for only one patient at a time, said Zach Hettinger, who practices emergency medicine at MedStar Union Memorial Hospital in Baltimore. That makes it harder to keep track of things, he said.\u003c/p>\n\u003cp>“You’re stuck with, ‘Do I cancel what I’m in the middle of and not complete that task? Or do I deal with the new task? Do I make a note somewhere — take scrap paper — or just remember it?’” said Hettinger, who’s also the medical director for the National Center for Human Factors in Healthcare and has researched how electronic records work in the ER.\u003c/p>\n\u003cp>How does that scenario play out? A triage nurse who is attending to multiple patients at once might scribble each individual’s details on the back of a piece of paper — ducking away later to enter the information into the computer system. That can make it easier to confuse things, and leave the emergency room short a nurse.\u003c/p>\n\u003cp>Computer systems need to better account for that potential human error, said Shawna Perry, an associate professor of emergency medicine at the University of Florida College of Medicine-Jacksonville, who has worked in multiple hospitals.\u003c/p>\n\u003cp>Stories of such near misses in the ER are now common lore, she added. In one episode, an electronic record system’s poor design, which made the appropriate medication dosage difficult to read, led to an instruction for a nurse to give a child a sedative 10 times the correct amount. The patient was fine, Perry said, but the incident demonstrates how a clunky or counterintuitive record can be dangerous.\u003c/p>\n\u003cp>“It was a simple slip of a cursor,” she said, questioning why the system even allowed the drug to be available in that strength for a 44-pound child. “How did this software fail its users?”\u003c/p>\n\u003cp>“That’s not an unusual event,” Perry added. “I know of many other situations. All of us do, by word of mouth.”\u003c/p>\n\u003cp>In fairness, electronic records have resolved many safety concerns, Pines said. They’ve rendered obsolete issues like misreading doctors’ handwriting. Accessing records is easier and faster, noted Dan Hampton, an emergency physician who works at Epic Systems, a major electronic health record vendor.\u003c/p>\n\u003cp>But because doctors don’t decide what a hospital buys, designs often emphasize what administrators or technology officials want, Pines said. To understand ERs, designers must spend time in them, Perry said.\u003c/p>\n\u003cp>“It’s one thing to have a computer, and informaticists on your staff, or have a doctor come in and look at this [particular design feature],” said Robert Wachter, a patient safety expert and interim chair of the department of medicine at the University of California, San Francisco. “It doesn’t get into this issue of what does it look like to be using this system at 4 in the morning, when you have nine other patients and a trauma patient running into the ER, and your beeper’s going.”\u003c/p>\n\u003cp>Manufacturers said doctor feedback is important and something they prioritize in their designs.\u003c/p>\n\u003cp>For instance, Epic, based outside of Madison, Wisconsin, sends developers to hospitals to study their needs, Hampton said. “Making our software easy to use is one of our top priorities, along with quality of care and patient safety.”\u003c/p>\n\u003cp>At Cerner, another vendor from Kansas City, Misouri, doctors on advisory councils give feedback on the ER-specific system. Representatives visit emergency rooms to hear from physicians, said Leslie Lindsey, Cerner’s senior manager of emergency medicine.\u003c/p>\n\u003cp>But there’s room to improve, Lindsey added. To address oral communication, Cerner sells supplements, like a phone-like device meant to fix communication gaps with emergency medicine. But hospitals may not want to buy add-ons when they’ve already paid tens or even hundreds of millions of dollars for a record system.\u003c/p>\n\u003cp>Despite these concerns, Pines said, it’s early. With time, companies will address kinks, so that patient safety issues diminish.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>“Think about where we were even 30 years ago with cars. Cars are rapidly innovating to become safer and more efficient — and I think we can expect to see the same transformation in the electronic health record space,” Pines said. “Things are improving. And things will continue to improve.”\u003c/p>\n\n","blocks":[],"excerpt":"In fast-paced emergency rooms, the implementation of EHRs is setting up a workflow mismatch and causing mistakes.","status":"publish","parent":0,"modified":1457051036,"stats":{"hasAudio":false,"hasVideo":false,"hasChartOrMap":false,"iframeSrcs":[],"hasGoogleForm":false,"hasGallery":false,"hasHearkenModule":false,"hasPolis":false,"paragraphCount":33,"wordCount":1486},"headData":{"title":"Electronic Health Records in ERs Causing Medical Errors | KQED","description":"In fast-paced emergency rooms, the implementation of EHRs is setting up a workflow mismatch and causing mistakes.","ogTitle":"","ogDescription":"","ogImgId":"","twTitle":"","twDescription":"","twImgId":"","schema":{"@context":"http://schema.org","@type":"Article","headline":"Electronic Health Records in ERs Causing Medical Errors","datePublished":"2016-03-03T21:45:01.000Z","dateModified":"2016-03-04T00:23:56.000Z","image":"https://cdn.kqed.org/wp-content/uploads/2020/02/KQED-OG-Image@1x.png"}},"disqusIdentifier":"122266 http://ww2.kqed.org/futureofyou/?p=122266","disqusUrl":"https://ww2.kqed.org/futureofyou/2016/03/03/electronic-health-records-in-ers-causing-medical-errors/","disqusTitle":"Electronic Health Records in ERs Causing Medical Errors","nprByline":"Shefali Luthra \u003c/br />\u003ca href=\"http://khn.org/\">Kaiser Health News\u003c/a>","path":"/futureofyou/122266/electronic-health-records-in-ers-causing-medical-errors","audioTrackLength":null,"parsedContent":[{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003cp>The mouse slips, and the emergency room doctor clicks on the wrong number, ordering a medication dosage that’s far too large. Elsewhere, in another ER’s electronic health record, a patient’s name isn’t clearly displayed, so the nurse misses it and enters symptoms in the wrong person’s file.\u003c/p>\n\u003caside class=\"pullquote alignright\">The ER’s culture and pace can amplify the risks of human error. Stories of serious near misses are now common lore.\u003c/aside>\n\u003cp>These are easy mistakes to make. As ER doctors and nurses grapple with the transition to digitized record systems, they seem to happen more frequently.\u003c/p>\n\u003cp>“There are new categories of patient safety errors” in emergency rooms that didn’t exist before the push to use electronic record systems, said Raj Ratwani, who researches health care safety and is the scientific director for MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C.\u003c/p>\n\u003cp>Spurred by the 2009 stimulus package and the 2010 health reform law, the federal government has offered hospitals financial incentives to adopt electronic health records that, among other things, will add efficiency and reduce errors by linking physicians’ patient records, and coordinating and tracking how care is delivered across the health system. Hospitals that don’t meet those standards are hit with penalties.\u003c/p>\n\u003cp>But in ERs, where things often happen fast, this push is sometimes setting up a technology mismatch that creates challenges that aren’t necessarily as evident in other parts of the hospital.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"fullwidth"},"numeric":["fullwidth"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Sneaker-clad doctors and nurses rush between patients, often juggling multiple cases. Verbal communication is key. Patients, even after being wheeled in by paramedics, can wait in a triage room for extended periods until a free nurse or physician comes to find out what’s wrong. It’s a different style of medicine, and one that’s often resulted in a distinct workflow.\u003c/p>\n\u003cp>As a result, the electronic record programs in many ERs evolved independently of hospital-wide systems. Since those homegrown, emergency department record systems often aren’t compatible with the newer, comprehensive ones hospitals are buying, they’re being phased out. The new EHR models are in many ways more efficient, but they may require adjustments.\u003c/p>\n\u003cp>The way the systems are set up, it can actually predispose to higher error rates,” said Jesse Pines, who directs the Office for Clinical Practice Innovation at the George Washington University School of Medicine in Washington, D.C.\u003c/p>\n\u003cp>In 2013, Pines, with other members of the American College of Emergency Physicians, wrote a report finding mistakes in the ER — like ordering the wrong medications or, because of confusing computer displays, more easily missing key patient information — were common after the switch to these digital systems.\u003c/p>\n\u003cp>“A growing body of evidence suggests that many errors may be the result of poor design rather than user errors,” the report states. That “can have a profound influence” on patients.\u003c/p>\n\u003cp>“It’s certainly a patient safety concern,” said Jason Shapiro, an associate professor of emergency medicine at Mount Sinai, who chairs ACEP’s informatics committee and co-authored the report.\u003c/p>\n\u003cp>There’s no research measuring how often these errors — like entering care instructions in the wrong patient file or missing instructions altogether — cause actual harm.\u003c/p>\n\u003cp>“We’ve got to figure out how we’re working with our electronic records, to make it part of the workflow,” said Nathan Spell, chief quality officer at Emory Hospital in Atlanta. Even when doctors have learned to use the record systems, missteps still occur.\u003c/p>\n\u003cp>The ER’s culture and pace, for instance, can amplify the risks of human error that stem from an already less user-friendly system. Think of the emergency physician who, reaching the end of a hectic 12-hour shift, looks for the record of a patient he just examined. He types in the man’s last name, clicks and writes medical instructions — not realizing that he’d accidentally pulled up the file of another patient with the same last name and similar age, who was admitted five minutes before.\u003c/p>\n\u003cp>While misidentifying patients in this way was hardly an issue before EHRs, it’s “becoming quite prevalent,” in this more digital era, Ratwani said.\u003c/p>\n\u003cp>Many systems, meanwhile, allow doctors to edit the record for only one patient at a time, said Zach Hettinger, who practices emergency medicine at MedStar Union Memorial Hospital in Baltimore. That makes it harder to keep track of things, he said.\u003c/p>\n\u003cp>“You’re stuck with, ‘Do I cancel what I’m in the middle of and not complete that task? Or do I deal with the new task? Do I make a note somewhere — take scrap paper — or just remember it?’” said Hettinger, who’s also the medical director for the National Center for Human Factors in Healthcare and has researched how electronic records work in the ER.\u003c/p>\n\u003cp>How does that scenario play out? A triage nurse who is attending to multiple patients at once might scribble each individual’s details on the back of a piece of paper — ducking away later to enter the information into the computer system. That can make it easier to confuse things, and leave the emergency room short a nurse.\u003c/p>\n\u003cp>Computer systems need to better account for that potential human error, said Shawna Perry, an associate professor of emergency medicine at the University of Florida College of Medicine-Jacksonville, who has worked in multiple hospitals.\u003c/p>\n\u003cp>Stories of such near misses in the ER are now common lore, she added. In one episode, an electronic record system’s poor design, which made the appropriate medication dosage difficult to read, led to an instruction for a nurse to give a child a sedative 10 times the correct amount. The patient was fine, Perry said, but the incident demonstrates how a clunky or counterintuitive record can be dangerous.\u003c/p>\n\u003cp>“It was a simple slip of a cursor,” she said, questioning why the system even allowed the drug to be available in that strength for a 44-pound child. “How did this software fail its users?”\u003c/p>\n\u003cp>“That’s not an unusual event,” Perry added. “I know of many other situations. All of us do, by word of mouth.”\u003c/p>\n\u003cp>In fairness, electronic records have resolved many safety concerns, Pines said. They’ve rendered obsolete issues like misreading doctors’ handwriting. Accessing records is easier and faster, noted Dan Hampton, an emergency physician who works at Epic Systems, a major electronic health record vendor.\u003c/p>\n\u003cp>But because doctors don’t decide what a hospital buys, designs often emphasize what administrators or technology officials want, Pines said. To understand ERs, designers must spend time in them, Perry said.\u003c/p>\n\u003cp>“It’s one thing to have a computer, and informaticists on your staff, or have a doctor come in and look at this [particular design feature],” said Robert Wachter, a patient safety expert and interim chair of the department of medicine at the University of California, San Francisco. “It doesn’t get into this issue of what does it look like to be using this system at 4 in the morning, when you have nine other patients and a trauma patient running into the ER, and your beeper’s going.”\u003c/p>\n\u003cp>Manufacturers said doctor feedback is important and something they prioritize in their designs.\u003c/p>\n\u003cp>For instance, Epic, based outside of Madison, Wisconsin, sends developers to hospitals to study their needs, Hampton said. “Making our software easy to use is one of our top priorities, along with quality of care and patient safety.”\u003c/p>\n\u003cp>At Cerner, another vendor from Kansas City, Misouri, doctors on advisory councils give feedback on the ER-specific system. Representatives visit emergency rooms to hear from physicians, said Leslie Lindsey, Cerner’s senior manager of emergency medicine.\u003c/p>\n\u003cp>But there’s room to improve, Lindsey added. To address oral communication, Cerner sells supplements, like a phone-like device meant to fix communication gaps with emergency medicine. But hospitals may not want to buy add-ons when they’ve already paid tens or even hundreds of millions of dollars for a record system.\u003c/p>\n\u003cp>Despite these concerns, Pines said, it’s early. With time, companies will address kinks, so that patient safety issues diminish.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>","attributes":{"named":{},"numeric":[]}},{"type":"component","content":"","name":"ad","attributes":{"named":{"label":"floatright"},"numeric":["floatright"]}},{"type":"contentString","content":"\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>“Think about where we were even 30 years ago with cars. Cars are rapidly innovating to become safer and more efficient — and I think we can expect to see the same transformation in the electronic health record space,” Pines said. “Things are improving. And things will continue to improve.”\u003c/p>\n\n\u003c/div>\u003c/p>","attributes":{"named":{},"numeric":[]}}],"link":"/futureofyou/122266/electronic-health-records-in-ers-causing-medical-errors","authors":["byline_futureofyou_122266"],"programs":["futureofyou_54"],"categories":["futureofyou_452","futureofyou_1"],"tags":["futureofyou_794"],"featImg":"futureofyou_122292","label":"futureofyou_54"}},"programsReducer":{"possible":{"id":"possible","title":"Possible","info":"Possible is hosted by entrepreneur Reid Hoffman and writer Aria Finger. Together in Possible, Hoffman and Finger lead enlightening discussions about building a brighter collective future. The show features interviews with visionary guests like Trevor Noah, Sam Altman and Janette Sadik-Khan. 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