Crash Cart: The Pain of Electronic Medical Records; Some Patients Still Demand White Docs; iPads Becoming Lifesavers

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This week: Digital records need redesign to avoid physician burnout; Asian American ER doc refused by white nationalists in Oregon; Two-way video calling tablets already saving lives in England. Join in as our editors discuss the week’s headlines.

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While Electronic Media Records (EMRs) should make health care better, they are a major cause of frustration cited by doctors and overhauling them is at the top of the list of ways to transform healthcare in a December 2016 STAT survey

They take too much time and focus attention on billing codes instead of the patient, notes Stanford School of Medicine Dean Lloyd Minor. Original Article by Quartz.

Nicholas Genes, MD, PhD: The Dean of Stanford thinks EMRs are a big part of the reason physicians are burning out. There’s no question that I enjoy shifts more when I have a scribe – I get to spend more time with my patients, and I don’t have a hundred onerous clicks waiting for me when I have to break away. But I can’t blame EMRs too much, either. There really isn’t any question that EMR has made tracking patients and reviewing records easier, and has made ordering meds and prescriptions safer. And the staff doesn’t seem to look forward to EMR downtimes, when we have to break out the marker boards, paper charts and order slips. No, the problems in EMR are due to the problems in healthcare – documentation burden is an outgrowth of what CMS and insurers insist on, for reimbursement, and what various regulatory agencies are looking for, to monitor performance. I don’t know if it seemed like a good idea, in 1997, to say an E&M Level 5 physical exam documentation would require two items in each of 9 separate systems, but that’s what we agreed to, and the EMR is there to make it happen (and if we miss an item, the billing company is happy to alert the administration to our deficiencies and lost revenue opportunities). The EMR is also where we’re documenting sepsis performance, as we wade through pop-up alerts part of a half-dozen Corrective Action Plans from the last few years. But every year, we see more and more patients, often sicker, without a commensurate increase in staffing or space or resources – so what might’ve seemed like a reasonable amount of charting in 1997 now seems stifling. Is it the EMR’s fault, or all the conflicting administrative goals that have been shoe-horned into it?

William Sullivan, DO, JD: The pull quote from this article is “EMRs aren’t working on the whole. They’re time consuming, prioritize billing codes over patient care, and too often force physicians to focus on digital record keeping rather than the patient in front of them.” Amen. Funny that I have seen some docs take into consideration what EMR a hospital uses before they sign employment contracts. The article calls for a “revamp of EMR design.” We’ve been calling for that for 15 years. The EMR companies don’t care. They make changes that suit their needs, not that improve operability or information sharing. I’ve worked with half a dozen EMR systems and I’ve yet to find one that doesn’t frustrate me on a daily basis. In fact, EPIC just rolled out an “upgrade” that significantly increased the amount of time it takes for me to chart and to discharge patients. Nick is onto something, though. EMRs were built to address an issue created by payers for healthcare. In order to minimize reimbursements, the payers keep changing the documentation rules, which results in changes to EMRs, which results in patient charts being overloaded with increasing amounts of irrelevant (and potentially harmful) information and metadata. I laughed when a colleague once told me that comparing EMRs was like comparing excrement, feces, and poo. Of course, you’ll also have to note what color that poo is, whether it is intractable or not, and whether it is an initial visit or a subsequent visit for the same. Don’t worry – there’s an EMR for that.

Ryan McKennon, DO: There are two problems with burnout caused by EMRs as Nick mentioned. The first is the EMR itself, designed with the end user as an afterthought. The second is that we have to document most of this stuff at all. Who does all this documentation really help? Certainly not the patient. Does the diagnosis of URI or pneumonia become more or less likely because I documented a lung exam? Does my documentation of the review of systems really help the next doctor in caring for the patient? Do they even look? These exams and questions need to be done but does the documentation of them help the patient? I know, I know, if you don’t document it, it didn’t happen. If I don’t document a time of death is the patient still alive?

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Dr. Esther Choo says a few ER patients refuse her care each year based on her race

She says patient prejudice is so common, many physicians “consider it a routine part of their jobs.” Original Article by CNN.

Nicholas Genes, MD, PhD: Kudos to Dr. Esther Choo, for seizing the moment and raising awareness about so much of the ridiculous crap so many ED physicians have to put up with. One of my favorite tweets during the dark period around Charlottesville was this one, also shared widely on Twitter.

William Sullivan, DO, JD: Good for Esther. Awesome to see her discussing the issues on CNN. Hopefully others can do as good a job as Esther does to shine a similar light on many of the other issues that affect the practice of emergency medicine.

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Though the University of Virginia has been experimenting with ambulance telemedicine, seven British ambulances equipped with the technology are the first in operation worldwide, linking neurologists to EMTs treating patients who may be losing two million neurons a minute due to stroke

Last year, Israel became the first country to offer its citizens emergency video conferencing. Original Article by VC Daily.

Nicholas Genes, MD, PhD: So this article is in Video Conferencing Daily, but it could have easily been Venture Capital Daily, as I often hear a lot of pitches about bringing more ED expertise to EMS staff, via technology. (We do have an innovative community paramedicine program at Mount Sinai, and I enjoy beaming into patients’ homes via iPad to help interpret the data EMS is collecting, and guide management, via our online medical control program. We’ve definitely cut down on avoidable ED visits and I think the patients appreciate the technology.) But when it comes to guiding care after a decision to transport has already been made, well, in NYC that’s just not such a huge concern. Our paramedics are well-trained, and transport times are pretty fast.

William Sullivan, DO, JD: Neat in theory, but color me skeptical. I’d want to see more data before jumping too far into this. Maybe there’s a place for video calling technology along side telephone triage, but we still need to see how it will be implemented, who will pay for it, and whether it has any effect on outcomes. Does it offer any advantages over simple telephone calls? Take a stroke patient, for example. It isn’t like EMS is ever going to be administering prehospital tPA. Even with a confirmed stroke in the field by newfangled video calling, the patient still needs a CT scan at the hospital prior to thrombolytics. Will EMTs waste more time transporting the patient because they are establishing and dealing with the video link than they would just “scooping and running” a potential stroke patient to the hospital? Remember how Google Glass was supposed to be the next revolution in medicine … until it wasn’t? Let’s see how prehospital videos affect care. Oh, and I’m putting paramedics on notice right now: the first time I get some medical video call that is oriented vertically instead of horizontally, I’ll lose my everloving mind. Not sure how many clicks it will take in an EMR to get the correct ICD-10 code for THAT diagnosis.

Ryan McKennon, DO: I cannot see much use with EMS for transport times less than about 30 minutes. Physical exam is almost never the bottleneck for giving tPA, its the CT and lab work. If EMS reports they have a stroke, clear the scanner and do the exam after the patient returns while they are drawing blood. I do like the idea of having someone on video at the other end of a 911 call (medic?) who can help the caller or other people first to an accident to administer BLS while EMS is en route. With the prevalence of smart phones and video messaging, the technology exists in the community already.

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