Physicians and technology: Hopeless or hopeful

Physicians universally love clinical technology but often resist business/information technology.

They are suspicious, do not use it well and complain it makes their work harder and not easier. Why is this the case? What can be done?

First and foremost all stakeholders are accountable for this situation. We arrived at this point because of all the actions of everyone, not a select group. Since this specific article is written for physicians, we focus on what they can do.

Physicians often feel information technology is being forced upon them and it makes their work more difficult instead of less difficult. It should be no surprise that they are frustrated, resistant and even scared.

EMRs were often sold on the following basis:

- Meeting a government requirement such as meaningful use
- The opportunity for increased revenue, which was often dwarfed by the cost — both financial and work flow — of implementation
- Benefits to other stakeholders such as population health reporting were either absent or only available at additional cost
- False promises and benefits that never materialized: ease of use, savings in the office, improved billing .... the list is endless.

Most physicians had little involvement with configuring their EMR, leading to problems with the EMR and workflow. Many were uncomfortable and lacked the technical background. Did anyone explain their role to them and the importance of having a physician champion? The work was left to those who knew little about how the individual physician practiced medicine. The result was often more work for the physician, less time with patients and fewer patients seen.

EMRs should allow the physician to document what actually happened in the encounter in the patient's own words with phrases that provide specificity and accuracy. EMRs should use sentences and phrases that fit what actually occurred during the visit, reflect the patient and allow the physician practice medicine. Few benefits, reduced workflow and more overhead — no wonder physicians are unhappy.

What if a physician consultant was assigned to implement the EMR for the practice? They could work with physicians to explain the decisions required and the opportunity to improve work flow and provide benefits — physicians with proper training vs. IT specialists. Physicians with the background who have taken the journey can assist their colleagues on the ground and in the field during implementation. What if the physicians in the practice reviewed their workflow and EMR requirements with an experienced physician consultant on site during deployment? Their own personal medical informatics officer. Would this have allowed the EMR system to be configured and deployed in a manner more consistent and less disruptive to the practice? Maybe even review the workflow to identify opportunities for improvement (from the physician's perspective) which could then be supported by a properly configured EMR.

The challenges I have observed firsthand with EMR technology include:

- EMR doesn't integrate with the physicians' workflow. This may be a configuration issue.
- The physician cannot document the encounter the way he/she would like. It does not reflect what happened during the visit.
- EMR overuse of templates reduces the visit to a checklist.
- EMRs built to document fee-for-service visits rather than value based programs. They are weak in documenting the management of a patient's illness.
- EMRs are built with canned phrases. The physicians may not have access to the words and terms he/she chooses to use.
- The history of present illness (HPI) is not flexible and does not reflect the patient's issues.
- The Review of Systems and Physical Exam need ease of use for adding free form text.
- Showing the actual work performed often becomes difficult as the EMR may have standardized documentation for a particular system or review.
- Dictation often addresses some of these issues but physicians are often not well trained in where, when or how they can use it.

By addressing these issues, we can make the EMR a friend to the physician by improving workflow and making life easier. The physician will become engaged and find new ways to use technology that serves them and the patient and not some distant stakeholder.

Addressing the issues does not have to be complicated or difficult.

Physician concerns with EMRs are real. If you perceive a problem, it is real. Physicians, administrators and support teams need to understand your issues and address them.

What's in it for the physician? An honest assessment of the benefits the EMR will provide to the individual physician and practice and a commitment to measure success against those benefits.

Use your staff wisely. Let staff perform routine EMR work without changing your workflow. Do not change workflow unless you are doing it to improve care and efficiency. Have them access or print information for you allowing you to spend time with the patient.

Configure. Proper EMR configuration is critical. It is a reflection of you, the physician, your workflow, how you do things and how you treat patients. Physician involvement is necessary for success, but unless physicians want to be involved this situation will not change. The EMR software should reflect how you practice medicine. While EMR software needs physician input it also needs input from technical support, which may be physicians with informatics background. All stakeholders have to participate in this effort. Critical information: Do not change your office workflow to suit the EMR but do not overlook the opportunity to improve the workflow to benefit the patient, you and your staff by leveraging the EMR's capabilities.

Handling documents. Handling documents can be frustrating because they slow you down and interrupt your workflow. Let your staff do this while you spend time with your patient. Your staff handles documents and you review them. Configure your EMR to prepare and send documents as much as possible. Let your staff offload you so you spend more time with patients.

Documentation. It is still an art form. Document enough to capture what happened and be useful to yourself and other clinicians. Do not write a book. Templates, dropdowns and checklists help but only when you helped create them (configuration). Otherwise they may reflect services you normally do not perform, creating risk and extra work. Make sure your EMR does not default to a maximum visit. CMS issued a bulletin in 2006 labelling this fraud.

Dictate. An easy way to document what happened during the encounter is to dictate. Most EMRs have very good dictating software. You do not have to dictate everything. The HPI is the most important. In a few words a physician can document the reason for the visit, the patient's concerns and the physician's thoughts. This detail and specificity improves quality, patient satisfaction and cost of care. Make sure your EMR can document the status or assessment of a disease and not just the diagnosis. "Diabetes stable on meds or controlled with diet" vs. Diabetes. Note: Dictation today happens right before your eyes. Just like your cell phone. No waiting like the old days. When you finish documentation it is in the EMR. Get proper training.

Training. Training is a must, and the better the training the better the EMR experience will be. Make sure at least two staff members are super users (vacation) and that you have sufficient training.

Patient access. Patients need access to their information in a timely manner. This allows them to be more involved, more engaged and more compliant. Access to information can increase patient engagement which can improve outcomes, satisfaction (for both physicians and patients) and reduce cost (IOM).

Look at your patient. Look at your patient and not the computer. They need to see that you understand what they are saying and you need to see the expressions (and emotions) on their face. Hand held tablets help. If not, take a break every 30 seconds and look at the patient and have a genuine discussion with them.

Systems must be intuitive, Amazon and Netflix come with intuitive systems. Forget the manual and training. Physicians and their staffs should be able to open and use an EMR the same way they can unlock a new car and drive away. This will take physicians, IT experts and intermediaries who know both IT and clinical medicine working together with a common goal: improving medicine. They must also produce reports that are easy to understand and allow the physician to make decisions that improve outcomes and the quality of care.

Dr. Mihale is currently the Chief Medical Officer of CareSync, CEO and CMO the Chelsea Management Group, an Assistant Professor at the USF College of Medicine and a Major in the US Army Reserve Medical Corps. He has consulted with over 1,000 providers in matters ranging from credentialing, quality of care, coding and billing, medical necessity and improving care to members. He has served as Chief Medical Officer or Medical Director for 15 healthcare technology, mobile computing, biomedical or health plan companies.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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