Electronic medical records need to better focus on patients

The biggest problem with today’s push for electronic medical records is an archaic user interface.

Physician Alexander Friedman, writing a scathing essay in The Wall Street Journal, agrees.

Today’s electronic medical records are written for the benefit of insurance companies, which scrutinize each doctor’s note carefully for billing purposes. But, as Dr. Friedman astutely points out, “thorough, efficient billing doesn’t translate to better care.”

It’s gotten to a point where some doctors print out pages of data to bring to a patient encounter, or scan in dictated notes; both of which defeat the purpose of digital records in the first place.

There are scores of electronic medical records competing the gain market share — but each fails to communicate with one another, and all are burdened with a user interface circa Windows 95 that impedes clinical care.

It’s imperative that we divorce charting from medical billing, update interfaces to today’s standards, and return to why doctors write in the medical chart in the first place — to easier treat and benefit the patient.

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by John Schumann, MD

One of the joys of practicing at an academic center is that I get to do many different things in my job.

The foundation of my work is seeing my own patients in a large group (more than thirty doctors!) primary care practice.

Two months a year, I take my turn rotating on the hospital inpatient services, supervising teams of residents and students who are the primary caregivers for patients with illnesses serious enough to merit hospitalization.

I also am a classroom teacher, team-teaching the Medical Ethics course taught to all first year medical students.

My work in ethics has afforded me another interesting opportunity, one that combines teaching with medical practice: For the past two years, I’ve been serving as our medical center’s living donor advocate physician.

It’s a mouthful to say, but here’s what it means: Patients that need a kidney or liver have the option of asking relatives or friends (even occasionally strangers) to donate their organs to them. This is because there are long waiting lists for both organs, and relying on organs from people that have just died (“deceased donors”) does not meet the need.

The government, in its role as regulator and payer for most transplant services, promulgated the concept of donor advocate teams to reduce the likelihood that transplant centers would either intentionally or inadvertently coerce potential living organ donors into following through.

Transplant programs like living donors for many reasons: the organs they provide usually work better and therefore last longer in the recipients; happier and healthier recipients enhance the center’s stats and build the reputation of the program; lastly, satisfied donors who have done the good deed of donation also help promote the program and the idea of organ donation in general.

Hence the need for donor advocate teams: “independent” professionals (I am not a part of the transplant program, nor do I receive any compensation from them for my involvement) that evaluate, advise, and “protect” potential living donors — both from the transplant programs AND from the donors themselves.

What does it mean to protect a donor from him or herself?

Relatives often feel compelled to donate organs to their family members–even when it doesn’t make sense. There’s an understandable impulse to want to help those less fortunate, especially when they are in the circle of our family, friends, or local community. Organ donation is such a concrete (but also symbolic) act of charity and goodness. So who are we to stand in the way of someone’s altruistic tendencies?

Here are the things I consider when I evaluate a potential organ donor:

1. Does the donor have all necessary and sufficient information about organ transplant and their role in the process?
2. Do they understand the proposed surgical procedure?
3. Do they understand what giving up part (liver) or all (kidney) of an organ means for their future health?
4. Are they considering this act out of true desire or for some ulterior purpose (money, publicity, selfless destruction)?
5. Importantly: is the donor healthy enough to be an organ donor?

There are other things that we consider, like the implications of the donation on other members of the family, potential lost income (organ donation is by federal law uncompensated), and employment and future insurability issues. We ask if the intention to donate jibes with the potential donor’s religious faith.

Occasionally, we are presented with situations that are even more ethically challenging than usual. For example, the intended recipient’s health insurer pays the donor’s medical costs for the evaluations, the surgery, and the post-operative care. This seems only fair. But given that there may occasionally be long term health consequences of living organ donation, should we allow donors without health insurance to donate? Recipients’ insurance typically do not cover donation-related costs beyond one year.

What if the willing donor is an undocumented immigrant? How does donation impact their legal status or chances for legal immigration? Should we take the high moral road of not allowing undocumented immigrants to donate, since at the very least it seems exploitative?

People often ask me how I know whether or not a potential donor is telling the truth or not with regard to their motivations. I reply that I’m a doctor, not an investigator; I don’t use a polygraph in my work. If someone is physically healthy enough and emotionally determined enough to go through with organ donation, I may not be able to ascertain their truthful intent.

Obviously, though, I always hope for the best. I take people at face value and try to help them through the process. I start with the assumption that people are acting truthfully. I certainly try to.

John Schumann is an internal medicine physician at the University of Chicago who blogs at GlassHospital.

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Originally published in MedPage Today

by Michael Smith, MedPage Today North American Correspondent

Physicians are working fewer hours than they once did, the result of a decade-long decline that coincided with lower fees for their services, a study showed.

After two decades of stable hours, a steady decrease began in 1997, according to Douglas Staiger, PhD, of Dartmouth College, and colleagues.

The decline coincided with a marked drop in physician fees, as measured by an inflation-adjusted fee index, Staiger and colleagues reported in the Feb. 24 issue of the Journal of the American Medical Association.

For nonresident physicians, the decline is equivalent to the loss of 36,000 doctors working at the previous hour levels, the researchers said. The finding may have implications for health reform, they added.

To calculate work hours, Staiger and colleagues used data from 1977 through 2007 from the Current Population Survey, which is administered monthly by the U.S. Census Bureau to a nationally representative sample of more than 100,000 people.

They found that from 1977 through 1996, work rates for all doctors were relatively stable at 55 hours a week, on average. But from 1996 through 2007, average hours fell 7.2%, reaching a low of 51 hours by the end of 2007. The drop was significant at P<0.001.

Among other findings:

* Resident physicians saw their hours fall sharply due to duty hour limits imposed in 2003. The decline was 9.8% and was also significant at P<0.001.
* At the same time, average work hours for nonresident doctors fell by 5.7%, again significant at P<0.001.
* Among nonresident physicians, the decrease was largest for those who were younger than 45 (at 7.4%) and working outside the hospital (at 6.4%). Both drops were significant at P<0.001.
* The decrease was smallest for those 45 years or older (at 3.7%) and working in the hospital (at 4.0%). The declines were significant at P=0.008 and P=0.03, respectively.

Between 1995 and 2006, Staiger and colleagues found, average physician fees nationwide fell by 25%.

They also found that in 2001 (the only year for which the comparison was available), doctors in metropolitan areas with the lowest physician fees worked less than 49 hours a week on average, while those elsewhere worked more than 52 hours a week. The difference was significant at P<0.001.

The change “likely reflects a combination of economic and noneconomic factors,” Staiger and colleagues said.

The drop in fees probably accounts for some of the change, they said, by reducing the incentive to work long hours. But other factors — such as increased competition and the rise of managed care — may also have played a part, they said.

The study was not designed to tease out any possible causal connection between fees and work hours, they cautioned. There were also no data on physician specialty, they added.

The “trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult,” Staiger and colleagues said, although larger medical school classes or more immigration by physicians could reduce that concern.

But the trend could also “frustrate stated goals of health reform,” which may require more doctors, they concluded.

Visit MedPageToday.com for more practice management news.

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What if your local hospital went national?

In a growing trend, big name institutions are partnering with smaller hospitals nationwide, looking to leverage their reputation.

Drew Weilage, blogging at at our own system, highlights a local hospital in Ft. Lauderdale, Florida which signed a partnership agreement with Boston’s Massachusetts General Hospital.

Indeed, he asks, “Who wouldn’t choose, if they could, the Mayo Clinic for neurosurgery? Or the Cleveland Clinic for heart treatment? Or Johns Hopkins for a urology procedure? Each of these institutions are ranked first in those respective specialties according to US News.”

Name recognition sways patients’ choices when it comes to medical decisions. That’s why big name institutions, like the aforementioned Massachusetts General, are able to throw their weight around when it comes to negotiating rates with health insurers. Patient demand gives them the upper hand when bargaining.

So it makes sense that the next step would be to expand nationwide.

What happens to the local hospital? It could be a win-win for everyone involved: “Think of your local community hospital offering the expertise of the nation’s best. It really could be a collection of partnerships with the best around the country. It is especially likely if a particular hospital trails the local competition: the other guy is pretty good at heart care, but we’ve teamed with the Cleveland Clinic to bring you great heart care.”

Or, maybe, it will lead to more hospital consolidation — which may not be a bad thing, given the advantages integrated health systems bring.

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