[MUSIC] Hi, this Bruce Darrow and this portion of the course is going to talk about how health information technology is used in the doctor's office. And for the purposes, we're going to be talking about an in-person visit for our patients to go to a doctor, a clinician's office. This does not include a virtual visit, phone call or video visit and this is distinct from what's a provider would be looking for from health. Information technology in an urgent care, emergency department or a hospital setting. So, we've only talked a little bit about what patients have told us from research about what they're looking for from a healthcare provider and what would cause them to recommend that doctor or provider. We know that they want to have a provider that they're confident in, that he or she has the ability to give good care. We know that they like the idea of clinicians working together and that the doctor provider that they see at any time has information available to them about what happened in terms of their care no matter where they received it or what type of care it was. We know that patients prefer providers who are listening to their concerns and share their worries. We know that they like providers who have on the premises cutting edge technology and we know that they like good access, they want to have it be easy for them to get in touch with their doctor or their doctors office. So if we think about what a patient centered agenda would be for health IT for provider, they would want the IT to do the following. They want the IT to help the provider project confidence and know what is going on, what the best plan of care would be for them. They would want clinicians who have information on demand, so that they know that they're working together and the information comes to the clinician in front of them as well as travels out to other clinicians who it will be involve in their care. They want to make sure that their provider is interested in what their worries are and that means that he or she is an active listener, and is really paying attention to him or her as a patient rather than being distracted by the computer screen or other information technology in the office setting. They want to know that the cutting edge technology on site makes things easier for the patient and the provider, potentially decreases the number of visits that they need to make. Increases the accuracy of the care that they're going to get, makes things safe. And then finally, in terms of better access, they want to make sure that providers are giving what I would consider to be telephone plus. It's not that they only can get in touch with their provider or the office by picking up the telephone, but the ability to use online tools, scheduling, mobile technology are all often that patients are looking for and would improve their experience at a doctors office. So, that's what the patient agenda looks like. Lets think about what the provider is thinking when he or she is going to be seeing patients in the office. And generally, the concerns of the provider are largely based in four different categories. And the way I would think of it is I really want to help my patient, but I am limited by the following. I have time pressures. I need to be able to see a certain number of patients in a certain given period of time, and I can't spend as much time with each of them as I want to. Second, I have financial pressures. The amount of money I am getting reimbursed is not going up. If it's going up at all as fast as my overhead and so the amount of resource I have to devote to each patients visit is going down not up. Third are there regulatory pressures. The number of things that the provider has to do to be in compliance with expanding regulations is only going up rather than down. And finally, technology pressures. Some physicians feel like the technology is either not supporting them in the way that they want or is actively hindering them or they have barriers that don't allow them to put the right technology in place in the first place and they feel constrained by the absence of appropriate technology. So when we got step by step through these four, here's what the impact is in terms of what the technology allows and what the provider is looking for. If we look at that first category, I have time pressures. Here are the things that from a technology standpoint a provider would be thinking. First of all, the provider is thinking, I have to close my note. So if a patient is coming to see me in the office, I have to a certain amount of documentation on a computer that captures everything I need to say about that patient. Whether it's what the patient told me in literal words, what it is that I found by looking up test results for that patient, what I told that patient in terms of advice, what I prescribed for that patient, what I ordered in terms of tests, what I found on examination. These are all things that I, as a provider would have to document and there's a certain amount of time involved in that. So part of the time pressure is the need to be able to document everything appropriately and in a way that will be viewable for the rest of that patient's life, and possibly beyond. This is more than just scribbling something on a piece of paper. This is part of the legal medical record at this point. So, there is time pressure to be able to just document appropriately. Next, there is time pressure to be able to manage all the information that's coming in. So if a patient comes in to the office and says, I had this test done elsewhere and I want you to review it and find that information and discuss it with me. Whether it's the results of an x-ray or radiology test, whether it's the results of a laboratory test, I'm just getting access to that information. It might be something that is very easy and simple. It might come directly into the electronic medical record that that physician is using. It might be more laborious. There may be a request for information that has to be filed and that increases the amount of time needed for that physician to have all the information necessary to provide the care, and extend that office visit beyond the time that the patient actually leaves the office room. And then finally, once the information has been document appropriately, there is need to be able to communicate out and that is also something that takes time. So in some cases, it might just be printing the information out and stuffing it into envelopes. Routing it by fax, routing it electronically. Just tracking down the information for all the physicians who need to be contacted and are eligible or appropriate to get the information can be a time consuming effort. So these are all things that contribute to the time pressures phase and technology's potentially helpful, but potentially in the way of getting these done in a time-sensitive and time-efficient way. The second category we talked about was financial pressures. As I mentioned, physicians feel like their costs are going up faster than their reimbursements. And so, there's pressure for them to figure out how to balance them. Sometimes that means making sure that the amount of time that they see each patient goes down, so they can see more patients per day. And make sure that their income is volume driven. Sometimes it means that's their ability to take money from their practice to do upgrades for their technology is going to be limited. And then in addition to that there are Federal programs and insurer programs that include pay for performance debt are counting on the ability of the provider to first of all meet certain quality metrics that are documented in the electronic medical records. And second of all be able to provide that information in sometimes a technology proscribed or specified way to the external site that is determining whether or not they're meeting this quality metrics. So these go into the different types of financial pressures, and how IT is affected by them, or contributes to them. The third category was regulatory pressures. And as I mentioned when talking about financial pressures, regulations are only going up. So for example, in the state of New York the New York state legislature from time to time gifts us as providers with opportunities to provide better care to our patients. And a couple of years ago they decided that any patients born between the year 1945 and 1965 had to be offered the opportunity to undergo hepatitis C testing. While there are clinical benefits to this regulation, it is also something new that providers now have to be able to do in addition to whatever they were doing already. They have to be not only offering that test, but also documenting in a retrievable way in their system whether or not they had offered the hepatitis testing to the patients. It's not enough to offer it and have your patients say yes, in which case you order the test, or no, in which case you don't. You have to be able to document that you offer and then your patient said no. So the IT and the need to document in an IT system is guided and increased as a result of regulatory constraints. Additionally, there are both the financial implications I discussed as well as public implications. So if you are a doctor taking care of a patient with a certain kind of heart disease and their heart disease would suggest that your patient should be on a certain category of medication It may be publicly reported how well you were doing in terms of your care. You may be faced with quality metrics that are visible to patients. And they will be looking at how good a doctor you are based on whether or not you were prescribing that medication to that patient category in terms of the heart condition. That means that you need to have an accurate reflection of whether or not your patients have that heart condition and whether or not you are prescribing that medication. So the ability to use the technology both to do the documentation and to do the reporting becomes something that is important form a quality standpoint and also visible to your patient. And then finally, the technological pressures. Here are the things that I tend to hear from clinicians who are complaining. They will say things like, my IT systems aren't good enough. I may be using something that needs certain baseline requirements but it really isn't designed for me. Or it isn't designed for doctors or it isn't designed for doctors in my specialty. I hear that it's not really suited to me. I am an orthopaedic surgeon but I need to document certain things because I am a foot specialist and this is sort of a general design for run of the mill orthopedic surgeon. And I don't care about all the range of motion documentation I can do for somebody's elbow, because I really need to document the range of motion in people's toes. So a common complaint of physicians is that their practice has been sort of what they need to do is so different from what every other doctor has to do that the EMRs just can't keep up with them. I also hear some people say that my IT systems take more time to use than paper, and certainly paper is a very flexible medium. It is possible if you really want to document the range of motion of each of your toes that you can throw something together on a piece of paper and be able to make arrows and check marks and have something that is very easy to document quickly in a way that would probably take longer to design and use on a computer. So It is a reasonable complaint and one that I hear and the more specialized the workflow for the clinician, the more I tend to hear that type of complaint. I hear about the expensive IT systems. So if you were a practitioner in private practice running your own system, especially if it's a small practice with one only or a handful of people, you may find it extremely cost prohibitive to be able to bring the best technology or the one that is most suited to what you need to do over to your practice. And then, the last one is just, my patients don't like my IT system, my patients don't like my EMR, I don't like my EMR. My patients don't like the fact that I'm looking at my EMR, I don't like the fact that my EMR is taking me away from my patients. And there's a sense there for a number of providers in an office setting that, despite the many benefits of having information available in a computerized system, having data that can be shared with patients and outside of your office, that having the ability to share it and go back and forth from a hospital setting to an office setting, to be able to take advantage of drug, drug, drug, allergy interaction checks, and all of the things that an IT system allows you to do. There's a sense that it's not medicine the way it was meant to be practice when I was taught about it in medical school. So these are the complaints that you'll hear from clinicians when they're looking at the way that IT affects their particular concerns. What I would recommend instead is taking the view point of the patient and seeing how the technology can help with addressing those patient wants. So if we go through them again, let's start with the first one, patients want to have confidence in their provider. And they want their provider to be using technology in a way that helps project that confidence and knowledge. What that means is, first of all, the physician has to show some confidence in his or her use of the IT. A physician who is sitting there cursing at their keyboard is not going to inspire confidence in a patient, no matter how good he or she is clinically. So the one thing that I would say as an initial prerequisite for that doctor is to show some competence with their IT system and not blame their IT system for getting in the way of patient care. If the IT system [COUGH] is viewed as a contributor to the patient care, rather than a barrier, that increases the confidence of the patient in that provider. Then you can go a step further and say, as a provider, you can use that technology to enhance care and not hinder it. And to do that you can highlight the ways in which it benefits a patient's care. I as a doctor can say, hey, I can access your records from that other hospital. I see the recommendations that this other doctor gave to you. I can tell what prescriptions were filled by your pharmacy. I know that you're not sure which medication that you were prescribed for this condition, but looking at your pharmacy records, I think I have a good idea and we can talk about what it is I can use the technology to make it easier for you to get your follow up appointment, for you to get your medication, for you to get your tests, for me to communicate with you when I have the results back. So these are ways in which if the technology is seen as an enhancer to clinical care, that it can increase the confidence that the patient has in the provider. The second thing that patients are looking for is clinicians working together. So they want the clinicians to have as much information as possible at their fingertips on demand. So what this means is that the physician has an opportunity to use the technology to make sure that they're getting information from other providers and clinicians. That they're sending it and sharing it with other physicians and providers, that they're sharing it with patients. Here, I'm going to send you the results of this test that your other doctor performed. I can release it to you in a way that you can check from your computer at home, and carry it around with you or download it. And they want to be able to take and send information back and forth to pharmacies. That becomes very important for patients on medications. They want to know that it's very easy for them to refill their medications on demand. The third thing is that patients are asking for providers who are concerned about their worries, and that means active listening. So from a provider perspective, the way to do that is to make sure that from the patient's perspective, the computer and the technology is enhancing care without replacing the patient. The computer and the technology should not be in between the patient and the caregiver. It's very important to be able to share that active listening, and any time the patient has the doctor bringing the technology, it should be explicitly seen as providing value to the patient in that experience. So when I am talking with a patient and I'm going through with them what I recommend for them or what I think they should be doing, if I'm bringing the computer, I'm usually explaining to them. I'm going to bring up your record here so I can prescribe your medication. I'm going to bring up your record so I can order this test, so I can check the result of this, so I can confirm when your next appointment is with your specialist. In that way, it increases the confidence in the provider, and it makes the technology something that is not replacing the patient as the object of the clinician's attention. The fourth concept was the cutting edge technology. And again, patients are telling us as clinicians that they like technology. So we are at cross-purposes with them when we are complaining about our technology. When we say, I'm so sorry, but I have to do this stupid thing that the computer is asking me to, this darn computer and this upgrade, or whatever. We can take advantage as clinicians of the fact that our patients like to see that we're using computers. They like to see that we are doing things that are enhancing their care and enhancing the quality and communicating with others. And then, finally, in terms of access and the ability to give telephone plus. This is one area where it's highly dependent on the abilities and the capacity of your technology. Some doctors have it set up that you can do secure messaging back and forth, or that you can release information directly to patients. Or that they can self-schedule their appointments or find out about the status of their test results. It's hard to fake that with technology, if you don't have it. So my advice is just to say embrace the technology to its maximum capability. And keep in mind that our patients are continuously going in this direction regardless of their age. I haven't met anybody below the age of 100 who doesn't like using a phone or a tablet to do Facetime with their grandkids or great grandkids. So it's not the technology. While some patients have a harder time learning the technology, you're adapting to it, everyone likes technology. And we as clinicians can embrace that and take advantage of it. [MUSIC]
