Perspective: It's not either-or for patients and EHRs

Studies continue to be released that decry the time physicians spend on computers rather than patients. These studies do our field a disservice because they don’t focus on the many ways EHRs have helped physicians do better for their patients.

A few weeks ago I saw a patient Friday afternoon after 5 pm. It was unscheduled and unexpected (someone scheduled for someone else who was running very late), and it was a simple acute problem, so I was asked if I would handle it.

Of course, my exam rooms were already turned down for the day (no lights, computers off). I decided to take the patient back, put paper on the table, turn the computer on, get the vitals, etc. Because it was a simple problem and the patient was a good historian, I decided to see if I could finish my visit before the computer fully booted up (we are a health system with multiple layers of security, so PC boot up from fully off to fully connected takes several minutes). And yes, I finished my visit and wrote a paper prescription for an antibiotic before the computer came up.

It was 100 percent eye contact, no paper, no PC, all face time--a very pleasurable experience for me and the patient. The patient could tell me no drug allergies, so the antibiotic I used (clarithromycin) wouldn’t hurt him. However, there were several things not so good about this 100 percent eye contact / 0 percent EHR visit.

One of the rarely discussed implications of EHR-enabled care (particularly true for providers in informational fields; less so for proceduralists) is one is not really asking for the same care as what we used to document on paper records. We are expecting the doctor to address the complaint that brought the patient in AND missing care opportunities. After the computer came up I saw that:

1. Patient was two years overdue for a colonoscopy.
2. We had no documented preventive gynecology care. Again, this was not my patient, and it was not clear whether the patient was seeing a gyn outside of MedStar, or the PCP had just forgotten to address this over the past few years.
3. We are doing Million Hearts at MedStar and this patient should have been advised to be on low-dose ASA but this didn’t happen.
4. The last labs showed an elevated sugar and the next visit was supposed to include an A1C test.
5. The patient was a smoker and had agreed to try patches and was to report back at her next visit on whether the patches helped.
6. The patient was also on a statin, so I shouldn’t have given clarithromycin.

What I am describing above is an example of moving beyond existential care (reacting solely to what the patient presented with) to a “shared agenda” visit – where BOTH the patient’s issues and missing care opportunities are prioritized and addressed (as time permits). Some of my colleagues have suggested that what I mention above would spell the end of volume and access, as every patient visit would now need an hour or more. For some exceedingly complex patients that may be true, but I would suggest that these exceptions are managed as we do now; doing what is most pressing first, and then having the patient return for the rest. That said, the story above is more typical of my patient visits.

The care opportunities described first appear to us (patient and me) as a global – so we could select all or a few. For example, our lab was already closed but with a few clicks I could have created the lab order or just informed the patient that she was overdue for a visit and labs (and flagged my partner who needed to do chronic care follow up).

1. Patient was two years overdue for a colonoscopy--“It appears that you are overdue for a colonoscopy – shall I order one today?” One click.
2. We had no documented preventive gynecological care--“Are you regularly seeing a GYN for pelvic exams and paps?”  If yes, single click; if no, patient advised to schedule with her PCP here.
3. This patient should have been advised to be on low-dose ASA--“This has nothing to do with your visit today, but as you know, we are trying to identify people at higher risk for heart disease, and you would benefit from low dose-aspirin. Are you already taking it?” Again, depending on answer – which can also be a decline--single click and done.
4. The last labs showed an elevated sugar and the next visit was supposed to include an A1C test--As above, I could have created the lab order for the patient, and the patient would return at her convenience to get it done.
5. The patient was a smoker and had agreed to try patches and was to report back at their next visit on whether the patches helped. “Did you use the patches?  Did they help?” I could at least get that. I probably would not have gone the next step if they didn’t help--as each of the docs in our practice does something a bit different--but at least I would have raised the issue. Also, it would have been pertinent to raise during a visit for a respiratory infection--as patients who smoke who get recurrent infections may be more amenable to suggestions to quit.
6. The patient was also on a statin, so I shouldn’t have given the clarithromycin, and I didn’t do a med review BEFORE prescribing the antibiotic, and I didn’t give the patient a clinical visit summary. I would have, of course, received the alert in real-time and backed off the clarithromycin and prescribed something else which would take a few seconds.

For me, it would have honestly taken an additional 1.5 – 2 minutes, and certainly would have caused me to read and think and explain more than I did. From a billing perspective, this evolution from a quick “fix this problem visit” to a “fix this problem and help take care of the entirety of me” visit may have justified an increase in billing level (perhaps from a level 2 to a level 3 visit).  The financial impact to the payer would have been a slightly higher bill for this “max packed” visit – but it would be less than having these all occur separately.  The financial impact to the patient would be to save money – as they would have one visit and one co-pay, instead of multiple visits and multiple co-pays (not to mention taking time off from work to see me).

Depending on one’s specialty, optimization of care, utilizing the infrastructure of the EHR changes the doctor-patient contract. As my patients have come to expect, they come in with their list and they know I will have mine. Patients may be offended if I were to be rude (I hope this has never happened) and ignore their issues for the sake of my issues.  However, I have found when both sets of issues are respectfully addressed, it is appreciated by patients.  I have been told more than once, “Doc, I know you are on top of things when it comes to my health; thank you.”

E&M coding is outdated and primarily relates to documentation of acute care and not what I am referring to above. That said, by creating apparent safe harbors from billing fraud with over-documentation, it has served as an impediment to optimization of EHR-enabled care--in particular the type of care I described above. 

EHRs need to improve and be made more usable and useful towards the overall mission of making care better, safer and more value-laden. How we optimize them within the evolving healthcare ecosystem will ultimately determine their value. Our shared goal should be to make the time “in front of the screen” of the highest value for doctor and patient; and not to consider screen time as something to avoid.

The author is medical director of ambulatory EHR and health IT policy for MedStar Health in Washington, DC.