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How do we bring back the art of medicine?

Technology is supposed to help physicians improve care of the patient. And yet, many physicians feel that the onslaught of procedure codes and electronic medical record note-taking has compromised the art of medicine. How do we harness the power of technology to bring the patient back to the center?

Last week, four top physicians came together to discuss what physicians struggle with in the workplace, and how technological solutions could help, rather than harm, their work quality and satisfaction. The panel on healthcare technology was hosted by Nuance Communications, a company focused on creating more human-friendly technology in the medical setting.

The theme of the morning was allowing doctors efficiency without alienation. The EHR (electronic health record), regulatory demands, and current reimbursement systems were all brought up as targets for reform.

Nuance Panel Discussion: The Art of Medicine in a Digital World, featuring Dr. John Halamka, Dr. Keith J. Dreyer, Dr. Adam Landman and Dr. Steven Stack.

Nuance Panel Discussion: The Art of Medicine in a Digital World, featuring Dr. John Halamka, Dr. Keith J. Dreyer, Dr. Adam Landman and Dr. Steven Stack.

The 2009 Health Information Technology for Economic and Clinical Health Act paved the way for electronic health records to legally replace physical patient records in the healthcare system. Next year, hospitals that don’t use EHRs will be penalized financially. If the EHR is so supported, why is it also hated? During the panel discussion, some common themes came to light about current frustrations with the EHR:

  • It brings a computer between the patient and physician
  • It forces a physician to spend precious time adapting to new technology
  • The design is based on fee-for-service reimbursement policies
  • It makes medical notes less meaningful
  • There is a massive amount of data presented in an unmanageable way

“So many physicians so intensely hate their EHRs…but only a fifth want to go back to paper and pen,” said Dr. Steven Stack, past chair of the American Medical Association and practicing emergency physician in Kentucky. “Our challenge is not to get rid of the technology, it’s to make it better.”

The panelists proposed ways to make physician note-taking more efficient, accurate, and personal. Dr. John D. Halamka, CIO of Beth Israel Deaconess Medical Center, has been developing a supplemental tool to the EHR in which patient histories would be events on a “wall,” much like Facebook, and notes would be group-authored like Wikipedia.

Dr. Adam Landman, CMIO of Health Information Innovation and Integration at Brigham and Women’s Hospital, discussed how the ACO (accountable-care organization) model of the patient-centered medical home has the potential to transform physician-patient communication and improve preventive care. For example, he noted, at Kaiser Permanente primary care practitioners can securely communicate over email with patients, and are granted work time carved out specifically for that communication. He discussed another method of supplementing the EHR that’s currently successful at urgent care clinics. Medical scribes, who are non-clinicians trained to record notes in the EHR, record the full patient encounter so that the physician can fully focus on the patient and sign off on the notes afterward. Supplementing the EHR with intuitive tools for physicians prevents the pitfalls of a “one-size-fits-all” system, which Dr. Keith J. Dreyer, Vice Chairman of the Department of Radiology at Massachusetts General Hospital, says leads to “frustrated user mode.”

Halamka noted that most patients don’t mind technology unless it makes the doctor seem less compassionate. He said a doctor switching from using an iPad to using Google Glass actually made patients happier because it frees up the physician for face to face contact with the patient.  Googleglass was mentioned frequently as having the potential to give doctors immediate and important diagnostic information without physically distracting them from the patient.

The panelists also expressed frustration with the lack of sharing between hospital systems, even those within walking distance of each other. It is also mired in the problem of fee-for-service reimbursement impacting the psychology behind diagnostic action.  In a fee-for-service system, a doctor might just order another MRI for a patient who has recently had one, instead of asking the previous physician to share the images. This hinders the patient both physically and financially. Halamka says this could be solved by cloud-hosted image exchange, allowing coordination between institutions.

Dr. Paul Weygandt, the moderator and Vice President of Physician Services at Nuance Communications, mentioned the common practice of doctors doing their dictations for notes at the end of the day after seeing many patients. He questioned whether the hastily recalled and written information could actually be accurate. Speech-recognition systems could help eliminate this problem.

A current issue related to EHR was the pending update to the current International Classification of Disease (ICD) system of codes that doctors must use to document their diagnoses and procedures to insurance companies. The current system, ICD-9, will soon be updated to a new version called ICD-10, which will vastly increases the number of code possibilities. While this can allow more specificity in documentation, it also creates headache for physicians to sift through the codes and choose the right one. There is room for improvement in the interface between the physician and the code system.

A common refrain in the talk on how technology can bring physicians back to the art of medicine was that physicians need to be involved. Weygandt noted that when physicians are engaged with designing and introducing an innovation, it’s always more successful with doctors than if it comes top-down from a non-physician.

Interested in hearing what more doctors think on this issue? Watch the Nuance video, “The Art of Medicine,” below:

Vidya Viswanathan

Vidya Viswanathan

    Vidya is the founder of Doctors Who Create (doctorswhocreate.com), which brings together people who want to change the culture of medicine to reward and encourage creativity. She is a first-year medical student at the University of Pennsylvania and is passionate about using the power of innovation and storytelling to improve clinical care.

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