How Doctors Think

Jerome Groopman, M.D. has taken on the arduous task of penetrating the minds of physicians in his latest book How Doctors Think. As I am always interested in knowledge management in the healthcare and life science industries, I was intrigued by the topic and have been reading the book. What is of primary concern to me is: given the vastly increasing amounts of information that physicians must consume and process, how can they best leverage this knowledge to improve patient care? Groopman offers little if any advice in that realm. "Keep an open mind," "listen to your patients," are all good suggestions but how and when does the physician keep up with the latest in advances in the field?

Groopman's driving concern is the accuracy of diagnoses; only by properly diagnosing a disease can it be effectively treated. This is fundamental to the practice of medicine and a principal which everyone in the healthcare industry can agree. Groopman then cites many cases where diseases were improperly diagnosed and why. He points out the differences between medical mistakes; technical errors such as picking the wrong leg to amputate, and misdiagnosis; a result of flawed medical thinking. He cites a study that states that the majority of errors in healthcare delivery were due to misdiagnosis.

Although better information management may reduce technical errors, medical mistakes, Groopman feels that electronic medical records may increase cognitive errors; errors created by flawed thinking. He feels that technology drives a wedge between the doctor and patient and encourages the type of mistakes he's seen in his studies. These errors are a result of an early misdiagnosis or framing which has been allowed to continue without question throughout the patient's case. EMR give an artificial appearance of legitimacy to doctors' notes which may result in propagation of cognitive errors.

Groopman sees this as black and white; EMR are dangerous and should not be used because they commoditize medicine and will result in more misdiagnosis. There is no question that there is a push to control, if not reduce, medical costs. To do that requires improving efficiency, automating and streamlining repetitive tasks is one of the first places where this can be done. Early EMR systems may have reduced a physician's ability to think freely constraining the diagnosis process but as systems evolve, and physicians provide more input, EMR systems will become less of a wedge and more of a bridge between physician and patient.

To alleviate the problem of the physician staring into the computer screen and not looking at the patient, how about a wide screen monitor in the exam room where both the physician and patient can look at the record together? Would this result in longer exams as the patient goes through each and every note? If the interface is well designed the patient should be able to grasp the information quickly. One day this information will be owned and controlled by the patients themselves giving them ample time to view it on their own schedule.

RHIOs Call in Sick

Information Week's cover story this week, Diagnosis Critical, paints a pretty bleak picture of health IT in this country. At issue is the ability to exchange patient data between healthcare providers in a Regional Health Information Organization (RHIO). I mentioned a RHIO which I had personally experienced in a blog last January; the Integrated Physician Network (iPN) Avista. Although RHIOs have some advantages for providers and patients, the economics are not sufficiently compelling for hospitals to create them without grant funding.

The failure of a role model RHIO, the Santa Barbara County Care Data Exchange, at the end of 2006 highlights the problems facing RHIOs and the exchange of patient information. The problems ranged from too ambitious to lack of community support, but in the end the providers could not see the value in the network. SBCCDE spent eight years building their network, if they had been able to accurately predict the time and expense in setting up the system they may have been better able to set expectations. But had they possessed that information at the start would they have proceeded with the project in the first place?

Integrated healthcare systems, such as Kaiser Permanente and the UK's National Health Service, have strong economic incentive to streamline processes and reduce costs, motivating them to persevere even when struggling against daunting cultural and technical hurdles. But the loose federation of healthcare providers in the U.S. doesn't have those incentives; the costs of inefficiencies just get passed along to the consumers.

The American Health Information Community, an advisory group to the federal government, is expected to recommend that doctors using health IT systems receive higher reimbursement rates for treating Medicare patients. Although creating financial incentives to drive health IT is a powerful motivator, there are people who feel that nothing short of a government mandate will be necessary to drive adoption. I'm all in favor of holding out a carrot, but do we really think using the stick will speed the process?

What's Next, House Calls?

A story on the front page of yesterday's Wall Street Journal describes a physician in Rochester N.Y. who started up a solo practice with just an office and a computer. After working as a staff doctor in the local hospital for eight years, Dr. Gordon Moore figured it took 19 separate actions and 253 feet of walking just to order a prescription refill. With his new software he can order a refill with a few clicks and zero feet of walking. What's wrong with this picture?

The implementation of EMRs in clinical environments is often met with anxiety, resistance or ambivalence. Due to compelling economic pressures on large hospitals they are placed in situations where they are obligated to implement the systems, often at high expense and risk. Smaller practices take a wait and see approach; the economic need is not seen as so compelling as to off set the risk and the pain of implementing the new systems. As I explained in an earlier blog, some of these practices have needed significant subsidies to get their systems up and running.

But when you have an important medical service, such as primary-care healthcare, saved from dwindling numbers of care providers by the implementation of technology, the benefits are undeniable. The key is to find the right combination of systems to fit the current and near-term needs. This may be easier in a solo practice than one with multiple physicians with conflicting needs or perceptions.

EMRs in Private Practice

I went in for my annual physical exam last week at my local doctor's office. Although I knew they were implementing an Electronic Medical Records (EMR) system there, I wasn't expecting too much, it is a relatively small practice and most EMRs are beyond their price range. As usual, I was given the obligatory paper sheets on which I attempted to record my medical history as well as that of the rest of my family. Fortunately, I don't have to remember too much although I couldn't tell you when was the last time I got certain shots.

I noticed that the nurses were carrying notebook computers around with them, not exactly handhelds but they appeared comfortable enough to carry. The whole office was apparently on a wireless network pulling up patient records from a central server and editing them on the notebooks. The paper form I had filled out earlier had been entered into the electronic record and the interviewing nurse simply ran down the list on the notebook and filled in other information using a scribe on the touch screen. What was even more impressive was the lab tests that were done earlier in the week by Quest Diagnostics had been integrated into the record and were available right there on my chart.

This practice is part of Integrated Physician Network (iPN) Avista; a Regional Health Information Organization (RHIO) including Avista Adventist Hospital and 14-private physician practices in the Boulder, Colorado region. The network uses an EMR from NextGen Healthcare Information Systems. The software will integrate with the hospital information system from Meditech Inc. The network has also completed a laboratory interface with Quest Diagnostics Inc.

Not only could my doctor order prescriptions directly to local pharmacies, he could also order lab tests and schedule consults with other practices, even those not on the iPN network (albeit using the lowly faxing capability). In the end the reduction in the amount of support services by switching to electronic records will be tremendous not to mention the reduction in number and cost of errors. This didn't come cheap however; the U.S. Health Resources and Service Administration has contributed $2.3 million over the next three years and the physicians and hospitals have put in another $1.5 million.

Those of us who are technically inclined may have a hard time getting excited about less than cutting-edge technologies such as wireless networks, and integrated systems, but for healthcare, and especially small practice healthcare, this is no less than earth shattering.

My doctor did point out a slight flaw in the system; back when they were still paper based the screening nurse would place a red card in the paper tray outside of the examination room indicated that she was finished and that the doctor could continue the exam. Now that they were paperless, the trays had been taken down and the doctors could no longer tell which patients were ready to be examined. EMRs have brought the practice of medicine a long ways, but some low tech information systems may still be superior.