Meeting with Dr. Wolver

We met with Dr. Wolver Dec 7.

She gave us an interesting perspective, focusing more on the primary care aspect of how EMR is changing the whole aspect of how medicine is practiced in the ambulatory world.  She mentioned lots of her work is done outside of the patient encounter even.  She spends lots of time preparing for a visit researching history and messaging.  All of this is made much more manageable by the EMR.  There is no need to hunt down a chart.

She also brought up an interesting idea: the Social Media EHR.  This is more than just a hospital having a facebook page, or twittering.  There is a push for an inpatient records to be updated continuously, by a tweet-like mechanism.  For example, the nurse gathers the vitals, she tweets is into the EMR.  The resident phones the family to talk about end of life decisions, he tweets it on the EMR.

On the first look, this appears fascinating and I got excited about ti really quick.  But then I thought about information overload.  That's a huge problem today.  I can find pretty much anything on google, but do I want to?  Having all these tweets about a patient would need to be organized...very well.  Where do you put the nurse's tweets, where do you put the resident's.  What actually gets put in a daily progress note?  do you even still have daily progress notes, or do you have a list of physical exams performed throughout the day that you can simply scroll through to see any changes?  This is exciting, but I am wary of some of the complications.

Then is the issue of how are you paid.  Do you bill for every tweet?  Can you bill for every tweet?  I presume not.  For all of the new ways of doing medicine to really catch on, the reimbursement scheme needs to change, too.

This leads me to Hello Health.  Dr. Wolver mentioned it and I just went to their website and looked it over.  I like the patient portal and some of the other features.  But what really caught my attention is they use many non-traditional ways of having patient encounters.  They have video, email, phone built right in to their EMR.  And they say they can bill for it.  I would like to know the details of that.

Another problem with all this change is that if the patients don't subscribe to it.  There will always be some who don't have email addresses, or don't use a computer.  Can you build your practice around electronic media if the patient doesn't use it?  Or can you simply adjust the way you do things for the small number of patients who don't use computers?

All in all, I look forward to continued changes in the way medicine is practiced, and the way it is documented.  EHRs are inevitable I suppose, and their utility is great.  Chris brought up a great point at the meeting, though.  With the various EMR programs out there, there HAS to be cross-talk.  We owe it to our patients to look for ways to be able to access their information regardless of where they have been in the past.  The companies need to see that not everyone will use their EMR, so they need to make it compatible with others.

Some talk of just getting a standard EMR for everyone to use.  I don't think I like that idea.  It would eliminate many compatibility issues, but introduce others of who actually develops it?  Who gets paid for keeping it up to date?  And not all hospitals and physicians can agree on one way to have an EMR.  Yes, I know it's very capitalistic of me to say this, yet I don't think I need to apologize for being capitalistic.  It is what has led innovation in many fields, and keeps us fresh.  Though we do have to put up with the money-hungry, but they will exist in any system.

Thoughts from reading

So far I've found the most interesting stuff in chapter 2.  It's all about data.  I'll just go through the chapter and give my comments about different sections.

What are medical data?

This section looked like it would be not very helpful, but it actually got me thinking about the different aspects of data, and what I usually automatically do with it.  For example, one of the questions after the chapter asks you what it would mean if your pulse were 100.  It can mean many different things, depending on the situation.  If I had just ran to catch up with my favorite ice cream truck, it would be a normal response to increased exertion.  If I were a pediatric patient, it could just be normal physiology.  If I were losing blood, it could be a sign on intravascular volume loss.  This type of thinking is helpful on wards.  When I analyze the vital signs, I should do more than just check if they are in the normal range.  Sometimes if they are in the "normal range" they aren't necessarily normal.  And I can think about the patient's condition beforehand, and then look for certain changes in the vital signs that could be a signal of pathology.  

Another part of the chapter talks about how medical terminology isn't standardized, and how it would be helpful if it were.   If the computer knows what the information actually means, it can perform tasks to learn more about the patient, or to survey patient charts, being very useful in research.  However, like I said in the previous paragraph, medical data are more than just a number.  They change depending on the situation and the patient.  This might be one of the reasons medical terminology is not standardized, yet.  It is complex and conditional.  If a program searches for all the patients with "hypertension" it would need many conditional statements to get the information that the researcher needs.  

Another part of the chapter has an interesting statement: "it is crucial that they do not trust their memory when caring for patients."  I've actually received conflicting training on this.  One of my medicine residents said that we should have our patients in memory, and that we should be able to present them without any notes.  Later, an attending taught me that it is foolish to do this, and that things can be forgotten so easily, which could result in errors.  I think there are things that are useful from knowing your patients from memory, though, even if you don't solely rely on our memory for decision making.  I should know my patients well, and not just rely on the chart to tell me everything.  When I do this, I can think about the patient and the disease process even when I am away from the chart.  

I was especially in accordance with the section on "Weaknesses of the Traditional Medical Record System".  As I posted before, with the capabilities we have today, computerized records provide so much more to the patients.  It's not that the doctor is lazy and doesn't want to flip through a few pages.  The charts can get huge, making it very difficult to find what your looking for.  Additionally, probably every time I've used a paper chart, I've had parts that I couldn't read.  That is not good medicine, and not good for the patient.  If it is not legible, it's like it was not written.  

All in all, this chapter got me thinking differently about the data I use and interpret.  It also gave me some ammo for convincing people that paper records are insane.