From the pages of In Business magazine.
Last November, after having to switch my insurance plan for 2018, I did my homework to search for a new primary care physician (PCP) based on my personal criteria. The woman I chose impressed me with the ease and confidence she exhibited in her video, and I looked forward to meeting her.
I still do.
In January I called to schedule my initial meeting with her, only to learn her earliest available appointment was in August. August!
I was able to meet with a delightful physician’s assistant and kept the appointment with my PCP, but I couldn’t help but wonder if the delay was due to a lack of doctors, an overworked staff, or both? (I’ve since been informed my doctor will be on maternity leave in August, and our meeting was rescheduled to October.)
Then I was assigned to write a health care feature on the changing face of the care team and learned of another development that was top-of-mind with area medical professionals. It pertains to the challenges they are having with electronic medical records (EMRs), which have had a profound impact on health care since their widespread adoption over the past decade.
In addition to hearing their stories, we spoke to Dr. Chris Mast of Epic, the Verona-based maker of electronic medical records software, as well as KLAS Research, a Utah-based research firm that is out to prove that EMRs are getting a bad rap.
On the question of primary care, WEA Trust’s Tim Bartholow has his own thoughts about what’s happening in the health care industry, although they sometimes come with a bitter pill.
But to learn how patient-care teams have been impacted by all the changes, I needed to go to the source.
I am indebted to the four ground-level caregivers and two administrators who agreed to share their comments. Some agreed only on the condition of anonymity, which I eventually extended to all.
Their words follow in narrative form and speak for themselves.
Comments from the trenches
Nurse, practicing 30+ years
“I work in a specialty clinic and have also worked in a hospital. One of the biggest changes that most health care workers have found is in the electronic medical record. There are some drawbacks. Many patients complain about the loss of face-to-face interaction because health care workers need to complete the EMR in a timely matter. Physicians are limited in the number of patients they can see due to the time it takes to order tests, documentation, etc. The benefit of EMRs, however, is the continuity of care with the patients. The patient’s happiness is paramount but [the system] doesn’t work if the staff is overworked and stuck behind a computer.”
Primary Care Physician No. 1, practicing 11 years
“I knew early on that I wanted to practice medicine. I’ve always enjoyed science and critical thinking, so I felt medicine was the best way to tie in my passion for helping others. If a patient comes to me with a complex group of symptoms, I like to be on the diagnostic workup side of things.”
Not what I thought it would be
“I honestly don’t think a lot of young adults going into medicine really know what it will be like unless they have physicians in the family. Many of us who are first-time physicians in a family learn as we go.
“I knew medical school and residency would be hard, especially because it usually means giving up an entire decade of your life to train. You put your career on hold for about 10 years while all your friends have graduated and started their careers. It can create challenges when it comes to family and social life.
“I definitely chose the right field. I love what I do, but, at this point in time, I wouldn’t push my children into medicine unless they knew exactly what they were getting into. Things have changed quite a bit since I began this process.”
Predicting change
“I don’t think anyone could have predicted how much the practice of medicine would change, especially in regard to patient contact and developing patient relationships. EMRs have changed that tremendously. The majority of what we do now is done on the computer. For each hour of patient contact, we’re spending two to three times more than that on documentation and charting. We’ve become medical transcriptionists, which limits our ability to practice medicine and form those intimate relationships with our patients. We’re just trying to get by and get our work done.
“On the other hand, EMRs were very well intentioned and have many positives. Communication between physicians has increased both within and outside of our medical systems. Patient care has improved due to our ability to communicate with outside institutions and the ability to see consultant notes almost immediately. It no longer takes days to wait for the paper chart to arrive. There are built-in safety nets, too, that I believe have resulted in fewer medical dosing errors due to the safety systems in place.”
A typical day
“I’m a bit unusual. From 8:30-12:30 and from 1-5, I’m in direct patient contact. This is part of why I have trouble getting my charting done. Many physicians document in between appointments throughout the day. I want to spend as much time with my patients.”
Charting at home
“Everyone struggles and discusses the amount of time they spend on the computer. I’ve refused to let go of my time with patients for charting purposes, at least on my clinical days. I’ve been told I need to be more efficient, that I need to work on my exit strategy and manage my time better so I can complete my documentation during the day.
“So I do a lot of my charting at home when my kids are sleeping. There are many sleepless nights. I have Wi-Fi in my car so I can chart when we’re on a trip, and I also chart on flights. Everyone works outside of the clinic, but some of us struggle more with documentation because of the amount of time we’re spending face to face with patients, and it’s impacting our work-life balance tremendously.
“Once a week I get a note about the number of charts that are overdue and not done within the 48-hour required amount of time. But it’s not just the patient note that takes time. Between health care regulations, meaningful use, and best-practice alerts, we’re constantly clicking on things and either postponing or acknowledging reminders. Our inboxes are also full of MyChart notes from patients, which is basically free medical care. I spend almost an hour a day on MyChart alone.
“Yes, things could be easier, but I love practicing medicine! I have great co-workers, and we are making a difference. I worry though, that may be changing for a lot of people because their patient contact time has decreased significantly so they’re spending a third to a half of a day in front of a computer instead of in front of patients.”
Lower job satisfaction
“I think there are fewer people doing primary care because our work is feeling less meaningful. I don’t think people have the level of satisfaction they might have anticipated.
“Right now we’re witnessing the highest levels of physician burnout on record. I think a lot of that has to do with the increase in documentation demands and a decrease in meaningful patient interactions. Physicians are frustrated. It makes it harder for us to deliver the quality care we’d like to be providing.
“Still, I love what I do! My days are filled with joy except when I’m playing beat the clock because I’m running behind on documentation. We get fined for having records open too long, and we’ve been told they’ll even get stricter when patients start gaining more access to their medical notes.
“My argument is that the patient doesn’t care when their note is done. They need their questions answered, they want great medical care, timely callbacks, or responses to their MyChart questions. I prioritize everything except the notes because that’s what my patients care about.
“Fining is very common, but it also works. I’ve improved. I don’t get fined as much anymore, but it just feels wrong.”
(Continued)
Primary Care Physician No. 2, practicing 37 years
“I’ve been in medicine a long time, dating back to when there were a lot of small, independent practices, and the newcomer was Group Health Cooperative HMO.”
A nostalgic view
“The way we gather and interpret information is immensely different than years ago. I used to use a hand-held Dictaphone and I’d step out of the room and dictate a note. It took very little time and billing documentation was much simpler. We used multi-ply carbon paper and a patient’s diagnosis and billing was all on one page.
“That’s all flipped now and data entry is the hardest part, in my opinion. I spend about half my time with data entry. Even when I’m sitting with a patient and talking to them, I have to be at the computer. The learning curve takes a while and the process is not simple. There’s a lot of bouncing back and forth between different screens. It’s much more time consuming and probably has removed any natural interaction between doctor and patient. Sometimes it interrupts your thought flow, but once a patient record is complete, it’s super easy to retrieve.”
15-minute appointments
“It’s common for me to see between 18 and 22 patients in a day. Patients are scheduled for 15-minute appointments unless I have a special case. So I see patients for about three hours in the morning and three-and-a-half hours in the afternoon. Often I have to go back into the EMR later to clean up or add to, or do billing, but I’m more efficient than some. Phone calls are all documented, as is MyChart.
“Documentation isn’t just typing, though. It’s coding, diagnosing, labs. Everything gets its separate box. There are just so many boxes! The good thing is, it’s all there.”
Better quality care
“Overall, I believe EMRs have improved care. Retrieving patient data is a breeze. We have automatic reminders for a wide variety of things — if the blood pressure’s too high, or to alert us to potential drug interactions or allergies a patient might have. So I think the quality of care is better, but the data entry part hasn’t caught up.
“In my opinion, primary care physicians are paid less than specialists because the health care system rewards procedures. In my case, I get paid more for removing warts and doing circumcisions while the lowest billing rate is probably for time spent in psychiatric counseling or treating depression.”
Part-time specialty physician
“Health care was a calling for me and absolutely is what I was meant to do. But you have to have a calling. If my kids had a calling, I’d support them, but I also think that overall, our health care system in the U.S. is tragically messed up.
“EMRs have made my job easier. My wrist used to hurt from going through paper charts, and now I can’t imagine going back to paper. The patients I see are just so complicated, so while you might not love what you have to do, it’s much better now.”
Typing woes
“Overall, dictating was much easier and there was less eyestrain. Now, if I dictate over a certain number of words, I’ll get charged for being overlong. That’s made me a secretary which is ironic because I’m
a bad typist and never wanted to type!
“On the other hand, in order to get paid we need to document everything, and it becomes very detailed. Our notes are tracked, too. So if you leave something out, they’ll get right back to you. Seriously? Someone’s watching how many words we use? It’s kind of weird. How are we affording those people?”
Procedures pay
“The shortage in primary care physicians is because of reimbursements! You go through medical school, have this huge debt, and want to pay it off. Anyone who does procedures or surgeries gets paid better. In my opinion, primary care doesn’t get the respect it deserves, and primary care physicians are way undercompensated.”
Administrator No. 1
“Where EMRs are concerned, the plus is the opportunity to have access to records from multiple sites. Before, the paper records had to follow the patient. The downside is, we thought it would solve efficiencies, and now a lot of the medical record is siloed by role. So where before you could flip some pages and look at the last 24 hours of a nurse’s or physician’s comments, EMRs are now much more difficult to navigate.”
Making accommodations
“What I believe to be true is that the record was designed first and we’ve tried to fit our processes and workload into that record. So it’s not as fluid as it could be. We’re trying to work with the vendors to improve the flow, but it’s slow going.
“I feel like we’re accommodating what has been built. From my perspective, the medical record has become a repository of data. It doesn’t necessarily flow to tell a patient’s entire story because you have to dig into different elements of the record to create that story. How can the record better work in the workflow as opposed to just collecting data points, so I can easily see the last 24 hours of my patient’s life?
“In the exam room, we’ve lost that rich eye contact of reading the patient, not just what they’re saying but how they’re responding.”
Administrative growth
“With advanced regulations in the last 10 years, we probably have additional roles we didn’t have before. So can we get the cost of care lower? You bet we can! That said, the regulations and requirements do beg additional positions, so administration probably has grown. Regulations come from the government, or insurance companies with prior authorizations, or coding and billing. Medicare is a big one, Joint Commission, the Centers for Medicare & Medicaid Services (CMS). That goes way beyond us.”
Administrator No. 2
“Of course documentation is a foundational practice in nursing and among physicians. EMRs have evolved over the last decade or so, and one of the challenges is that, for the most part, it was implemented on the technological side without really considering the user side. So when you think about the provider — whether the physician or the nurse — what has been challenging is when they’re trying to work with a system that may not allow them to do the type of documentation that they need to do in the most efficient way. That will then hinder care delivery on both sides. I think that’s what we’ve been hearing.
“If you have providers who aren’t as technologically savvy, there’s a learning curve. On the other hand, being able to access patient information more readily and not having to ask patients or their families the same questions over and over again is advantageous.
“As for acquisitions and consolidations, in the future, what I hope would happen is that we really look at reducing redundancy. Not everyone needs to be the expert in everything.”
(Continued)
The Vendor, Dr. Chris Mast, vice president of clinical informatics, Epic Systems
According to Epic System’s website, 190 million patients have a current electronic health record that uses Epic software. There’s a reason for its success, notes Dr. Chris Mast, the company’s vice president of clinical informatics.
From the very beginning, Epic’s software has been designed in concert with those actually doing the work, he explains. “The developers who write our code must spend regular time with those using the code no matter where it’s being used, even if it’s in the operating room.”
In fact, they sit elbow to elbow to make sure the tools are honed to the user’s specific requirements.
The company, Mast says, is well aware of the knocks it receives. He attributes it to working in an industry right now that is in the midst of a revolution, in a sense. “We’re a global company, so while we may involve thousands if not hundreds of thousands of users in our design plans over the years, we have millions of people who use the software.”
He acknowledges the gripes about documentation, but asks for some give and take. “Many of us trained in a very different way. Everything I learned was paper-based, but now we have different tools and we’re still trying to get our heads around how best to use these tools optimally.” That might require giving up some old habits, perhaps, or simply being willing to do things differently.
“Most of the doctors I speak with feel they’re giving high-quality care,” Mast adds, “but frequently we find clinicians who just don’t like doing work that they feel is unimportant, or things they believe someone else, not a doctor, should do.”
The company has tools currently that can help identify those who may still be doing things the hard way, he says. “We can identify which tools they’re not taking advantage of to make their lives easier. It’s all about making patients, doctors, and nurses healthier and supporting them.”
So is Epic behind the idea to fine clinicians for late notes or using too many words?
“That’s not coming from us,” Mast insists, though he recognizes that medical groups have to sometimes impose their own rules. “Bills need to go out and payers need to pay.”
Automated systems don’t always reduce staff, either, he adds. “EMRs can enable efficiencies, but they also may add more capacity to what can be done, so my guess is that some organizations are having to repurpose their staff to compensate.”
Given the vast amount of work to be done, Mast balks at the suggestion that EMRs are still in their infancy. “I certainly don’t think we’ve reached our end state by any means, but we’re not toddlers anymore. We’ve figured out a lot of the nuts and bolts, but we’re a long way from where many of us envision.”
And that’s where the future of health care really gets turned on its head.
A click-free zone may be coming soon to a medical office near you. Currently, a clinician interacts with Epic software using a mouse, keyboard, and a computer monitor. Some of that attention may soon be drawn away from the computer screen through the use of virtual assistants.
Think Alexa.
Consumers are already interfacing with MyChart through Alexa to find out when their next appointment is, and Epic is moving down that road. â©“The idea is for the software to become an intelligent assistant,” Mast says. “We’re actively working on that.”
But the company is going even further, he explains, and exploring the idea of having a virtual presence in the exam room, whereby a computer listens in while a physician meets with a patient, tees up orders and interventions as appropriate, and documents things as the doctor works with the patient. “My role as the doctor then, is talking with the patient, making the decisions, and then confirming with the patient what the system has extracted from that in terms of next steps,” Mast explains.
“So have we come a long way? Yes. Are there exciting things in the future? Absolutely!” The future of health care will look very different just a few years from now, Mast promises. “We understand that more than anything, doctors and nurses want to be helping patients, diagnosing their conditions, and interacting with them. Epic is developing the systems and tools to support that.”
The Researcher, Taylor Davis, KLAS Research, vice president of strategy and development
KLAS Research is a Utah-based health care IT, data, and insight company doing research on the software and services used by providers and payers worldwide. As vice president of strategy and development, Taylor Davis has his hands full.
He compares the EMR revolution’s impact on health care to the automobile’s impact on the horse and buggy.
But after learning that only 7% of health care organizations were regularly soliciting feedback from their end users about how satisfied they were with their electronic medical records, KLAS designed an ongoing study designed to measure and benchmark how companies are using the technology.
At the time of this interview, Davis says nearly 35,000 perspectives from clinicians had been collected, 100 health care organizations were on board, and another 150 were expected to join by the end of this year.
The initial reports show vast differences, Davis reports. Some member organizations had 90% of physicians consistently happy with their EMRs, while others had the opposite experience, with 70% to 80% of physicians extremely unhappy.
“The big story is not that EMRs are destroying the world, or that regulatory burden is impeding success — which is flatly untrue,” Davis explains. “The big story is the huge variation in the success rates. We need to learn from the successful organizations. If we do that we can all be successful.”
He is convinced that sharing best practices related to EMRs is the key to the health care industry one day reaching a point where clinicians will thank their IT staffs for revolutionizing medicine. “But we’re so far away from that right now.”
And the consequences could be dire, Davis warns, because patient lives hang in the balance. “If we wait on sharing this info, we can start to believe that EMRs are the enemy and really lose hope. The industry is losing a lot of hope already in the EMRs, which is just such a shame.”
The Watchdog, Dr. Tim Bartholow, VP/chief medical officer, WEA Trust
Dr. Tim Bartholow has long been an outspoken critic of health care spending priorities. While this article isn’t tackling the rising cost of health care specifically, Bartholow argues that the more a community spends on brick and mortar facilities — and the administration that comes along with it — the less they’re prioritizing primary care.
“In health care, when you spend millions on a new facility, you should weigh the balance between needing a new building or investing in addiction care, behavioral health, or primary care.
“Every time you build a building in health care, you have to realize there’s no money tree, and when there’s no money tree, then a dollar invested in a building when you don’t have primary care is a conscious decision to have less primary care. I don’t think our communities think about it that way. They’re not looking at it as a tradeoff, but that would be an error.
“Some of our patients can’t afford albuterol for their asthma. That’s not an expensive medication, and I’ve got scores of these stories. When they come to a building with new features, marble, waterfalls, a big gym, swimming pool, what must they be thinking? How are they supposed to trust us? ‘Is this for me? I can’t afford my albuterol. Will my heart heal faster because there’s marble in the building?’
“In downtown Madison, we’ve spent over a billion dollars on medical buildings in a decade, but we can’t get people to addiction services. There’s not enough primary care access or behavioral health services. And what are we doing about it?
“We’re churning out a lot of specialists — we have a shortage of psychiatrists, general surgery, or OBGYNs in rural areas, but there’s no shortage in orthopedics.
“Other countries actually pay specialists and primary care physicians more closely. Here, a specialist may make three to four times what a primary care physician makes.
“For the lady who can’t afford her albuterol, what does she care about artwork, or a giant atrium, or marble waterfalls?”
IB would like to hear from more health care workers — anonymously or otherwise — about what they’re seeing on the local health care scene. Sound off in the comments below.
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