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Re: Rep Retirement Lodge: The Banana Bread Is Running Out
I would agree re the HMOs. They were good in theory but unfortunately they marketed themselves as an answer to everything and then rejected what they wanted. I don't have any problem with PAs for many things. There are a lot of tests ordered because of lazy medicine, not wanting to deal with entitled pts and for legal protection. That is a whole other ball of wax. In general Americans pay bloated costs because we don't have any regulation on how insurance co. make money. Because they pay so much they are ridiculously entitled. Insurance co exploit this by creating the 'satisfaction measure'. Insurance co win. Pts think they are winning and the Providers are screwed.
Some of this is insurance changing how they allow referrals and the systems the PHO uses. You look at this as streamlined but more of the burden (and time suck) is on me with multiple info to fill in and review. Previously I wrote the note. My staff did the rest of the work using the evidence in my note. Now the Provider is spending time to do things that previously they delegated to lesser paid individuals. They may cue up the specialist where you live but that doesn't happen in our area.
I used pocket scripts which I loved. NO problem with that. However- I could also call the pharmacy and tell them I had a sick person coming to pick something up could they fast track it. Now it has to be faxed or you are penalized. We used to call it in and then fax over- now that is penalized too. Around here this means pt can wait >1 hour, sometimes >2 to get a script that they could have gotten much faster if they presented paper. THe system we were using sent it thru a 'clearing house before it went thru to the pharm. Not a fan.
This is a good thing.
Most of the older providers are not happy with what has been lost vs what is gained. They suck it up or they get out of Practice. There are a lot who get out.
There is note bloat because when you want to look at a patient and you don't have all the info in one note then you need to access it thru multiple windows. If you don't include everything then the next person in has to go searching for that info and if they are pressed for time they don't have... Also legally you can't assume I saw that data. If it isn't noted then I didn't consider it. ALso- if you have ever rec'd medical records from a transfer you wouldn't ever say this. Most systems don't talk to each other. I used to get 3 inches of printed records from Harvard. All in a mash. If you get a summary it doesn't include everything. They may have found a way to put things in little boxes to be neat but work flow wise it is a lot of extra steps and if you are intaking someone= shoot me now.
This is not phones. You are an audiovisual aid for their findings. If you are using something to look at data and referring back to it I am sure it is fine. If you are looking at concepts, needing to remember details about certain things you don't do as well. That is why I said it worsens with complexity.
I'll add a quote from Plato's Phaedrus:
It maybe easy to click but does it end up conveying anything useful? I could look at the Cario consults for 7 patients and if the age and sex were blocked out they were interchangeable. The care is still happening. There is a note that checks the boxes so the person is legally covered but it is totally useless in conveying what really happened beyond simplistic info.
Originally posted by Swansong
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You've given a thoughtful response, so I'll retort in kind. Please don't misunderstand disagreement from snark or dislike. 
The business side was less complicated because costs - and I'm speaking of the cost of care, not the added stuff like compliance and whatnot - were lower. MRI machines cost an obscene amount of money, so you're **** right insurance companies and Medicare want to make sure your order of that MRI is justified (look up PAMA if you want to get really enraged). But just because it was more simple does not mean it was less a business. And if you want to be totally correct about when did it change, I'd argue that the introduction of the HMO in 1973 was when things started changing.
The business side was less complicated because costs - and I'm speaking of the cost of care, not the added stuff like compliance and whatnot - were lower. MRI machines cost an obscene amount of money, so you're **** right insurance companies and Medicare want to make sure your order of that MRI is justified (look up PAMA if you want to get really enraged). But just because it was more simple does not mean it was less a business. And if you want to be totally correct about when did it change, I'd argue that the introduction of the HMO in 1973 was when things started changing.
This is more of a philosophical question, but to that end I agree completely and think that, despite the learning curve issues we face, EMR's in general have streamlined zillions of formerly frustrating workflows to single button clicks.
Example 1: 20 years ago if I needed a referral to a specialist, my doctor would give me their name. I'd call and ask for an appointment. They'd get my insurance info, process that, and call me back and tell me I needed to call my doctor for a referral or pre-authorization (some offices might do that for me). They'd fax something to the insurance company, and to the specialist office. Then the specialist office would call me back and schedule an actual appointment. Now, if the referral is internal (within the same hospital/practice network), doctor places a referral order, the EMR checks insurance requirements for pre-auth and whatnot. If pre-auth is required the doctor fills out the form right there. It then creates a task in the scheduling work queue of the specialist's office. They call me and schedule, and I show up. With proper configuration, that's 3-4 phone calls, printing and faxing back and forth several additional forms, all replaced with potentially half a dozen clicks.
Example 1: 20 years ago if I needed a referral to a specialist, my doctor would give me their name. I'd call and ask for an appointment. They'd get my insurance info, process that, and call me back and tell me I needed to call my doctor for a referral or pre-authorization (some offices might do that for me). They'd fax something to the insurance company, and to the specialist office. Then the specialist office would call me back and schedule an actual appointment. Now, if the referral is internal (within the same hospital/practice network), doctor places a referral order, the EMR checks insurance requirements for pre-auth and whatnot. If pre-auth is required the doctor fills out the form right there. It then creates a task in the scheduling work queue of the specialist's office. They call me and schedule, and I show up. With proper configuration, that's 3-4 phone calls, printing and faxing back and forth several additional forms, all replaced with potentially half a dozen clicks.
Example 2: 20 years ago when I needed a medication ordered or refilled, they'd write down on a piece of paper the order. I'd take it to the pharmacy. I'd wait (or, more likely, come back later), and pick up my prescription. The doctor has no earthly idea if I actually dropped off the RX or picked it up. Now, with services like Surescripts, the doctor orders said medication, it checks for pre-auth requirements and can check if it's covered by insurance on the spot, and then travels via Surescripts to CVS. CVS confirms receipt, then confirms the fact that I actually went and picked it up (or that I did not).
Example 3: 20 years ago, doctor shopping for opioids was extremely easy since records were on paper and, except for pharmacy reporting to the DEA, hardly tracked. Now we have automated tools for opioid equivalence, pharmacy validation of pickup, outside record validation (did the patient seek a non-system doctor for the same medication, sent to yet a different pharmacy?). ED's love this as it's significantly reduced ED-related opioid abuse and fraudulent ED visits.
It's far from perfect, but again if we had not been so obstinately against digitizing, we'd have resolved the growing pains by 2010.
It's far from perfect, but again if we had not been so obstinately against digitizing, we'd have resolved the growing pains by 2010.
Again, in general I agree with your first sentence. But most providers and medical staff are doing just fine and will do just fine with whatever EMR they're using and whatever EMR comes next. And I'm not sure how any system - paper, digital or plain witchcraft will stop patients in your example here. If a patient lies, they lie.
One nit to pick - modern systems allow you to have your notewriter and various other data-filled windows open at the same time. This is somewhat recent (within the past 5 years?). I agree that it would be a total pain in the *** to bounce around between note editor and other windows. But this is less an issue. Also, embrace discreet data and avoid note bloat. Some patients are complicated and require dissertation-length notes. If it's needed, I'd certainly defer to your clinical judgement. But I see insanely long notes on patients who are totally healthy. Why? Lab results are filed appropriately. Medications are filed appropriately. Why do you need 5000 words to write that "Patient healthy. Weight creeping up but not yet an issue. Advised to watch diet and return in 1 year"?
Embrace the data. Learn to use the system to get the data you need. Patients are complicated and filing labs with labs, medication with medication, imagery with imagery helps categorize it. That we can also use it to help (ensure?) clinically appropriate treatment is given is a benefit, not a detriment.
Embrace the data. Learn to use the system to get the data you need. Patients are complicated and filing labs with labs, medication with medication, imagery with imagery helps categorize it. That we can also use it to help (ensure?) clinically appropriate treatment is given is a benefit, not a detriment.
Does that research include portable device screen time? If so, I'd agree (Without looking into it). But I'm on a PC all day, and my entire job is based on analyzing issues. I'd say that the millions of business system analysts in the country would disagree with that research if it does not exclude phones.
I'll add a quote from Plato's Phaedrus:
I'd further argue that clicking "why did the patient come in, what did we do/discuss, how long did it take and what orders should I place" isn't exactly complicated, but your mileage may vary.
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