EHR's for surgeons/specialists

John Halamka published an interesting blog on Tuesday, November 16 concerning some of the challenges of EHR use for surgeon practices. Some of his comments were spot on. Others engender further comment. I think many of Dr. Halamka's observations could be extended to the entire spectrum of medical and surgical specialists.

1. Surgeons do tend to treat patients who require relatively short term episodes of care rather than numerous patients needing long-term management of chronic diseases. Surgeons see their patients frequently, though over a time horizon of weeks or months but not often years.

2. Capturing useful and required clinical documentation, "getting it down" as my former mentor Dr. Mel Jahss called it, is a challenge for all clinicians. Template driven documentation, while often effective in primary care practices, is problematic in many surgeons' practices. Documenting the history and care plan for new patients often requires nuances that are difficult to capture with templates. Dictation has been a satisfactory but expensive solution. Informaticists however, eschew unstructured dictated notes in favor of structured documentation. Perhaps natural language processing will make it possible to generate a structured format useable for machine computing.
On the other hand, SOAP note templates for inpatient and outpatient follow-up visits can expedite documentation to save time and improve the quality of this type of documentation by increasing legibility and completeness of the note.

Four years ago in my practice, I gave an older version of Dragon a try for a year but found the results unsatisfactory. It was not possible to dictate and edit simultaneously. There were enough errors created by the software that editing was required to avoid embarrassment. I did not have the time to review every dictation in detail. Also, the technique for dictating in a voice recognition environment was quite different from using human transcriptionists who, when good, edit on the fly and clean up the dictation. I tried an online transcription service for awhile. The output was error-filled. I had a relatively low volume practice but ultimately found a local transcription service with a 24-48 hr turnaround time that cost $800-$1,200 per month for an excellent result.

Most surgeons do not use templates for their frequent procedures. There never seems to be the time to create templates even though they could save loads of time in the future. Here again, "getting it down" is the problem. I think surgeons would work collaboratively with clinical informaticists who sit down with them and help create templates for the three or four most frequent procedures. This service could be provided by implementation specialists for EHRs to promote process change. If you can prove to a surgeon you can improve practice efficiencies and save time needed to accomplish required tasks, they will gladly change and adopt health information technology. This is an area where a little hand-holding could go a long way to enhancing usability and physician satisfaction with electronic clinical documentation systems.

3. I think physicians climb a slippery slope when they decide to delegate tasks to mid-level personnel. Excessive use of such staff may contribute to decreased quality of care and patient dissatisfaction with the amount of time their physicians spend with them. I know I can take a much better history and perform a better physical than providers who have not been trained as physicians. I admit to my biases, as an orthopedic surgeon, based on numerous experiences dealing with unsatisfactory orthopedic care provided by untrained or poorly trained mid-level providers who are ubiquitous in urgent care centers and the less acute sides of emergency departments. I am in favor of the use of staff as scribes to "get it down." Mid-level staff can be trained to take vital signs and obtain past history (or abstract this information from a summary of care document.) I firmly believe that the physician is the best person to decide on the correct diagnosis and procedure codes. I also concede that inadequate resources have been devoted training residents in coding and other business process. Moreover, post-graduate physicians focus primarily on clinically oriented CME activities. This needs to change.

4. The development of interoperability and heath information exchange capabilities are as important to surgeons as primary care clinicians. As already mentioned, when clinical summaries become available from referring clinicians, the safety, efficiency, and timeliness of care will improve. Surgeons often need access to laboratory results for studies ordered by primary care providers. Having that information available through information exchange would save patients and the system by avoiding redundant testing. Furthermore, E-prescribing, which depends on information exchange, offers the same benefits to surgeons, other specialists and patients as it does for primary care clinicians.

Many types of specialists are increasingly dependent on imaging information to make diagnostic and treatment decisions. In many cases these images are stored by different service providers in silos that are difficult to access, even with the use DICOM and other imaging standards. Interestingly, the meaningful use initiative has not placed a high priority on imaging despite the explosion in the number of imaging studies now being performed. Imaging is barely mentioned until the Stage 3 proposals. Today, as an orthopedist I am still mostly provided either hard copy x-rays or digital images on portable media (CDs) by patients who had imaging studies outside my home institution. That is, if they remember to bring the "films" with them to their appointment. A few imaging providers offer access to their systems through proprietary portals but each requires downloaded software and separate logon credentials. I also want to emphasize that I need to see the actual pictures. A radiologist's report is never adequate in my line of work. I am sure this is true for other specialists as well. The ONC should adopt imaging standards and promote the exchange of imaging information in Meaningful Use stage 2 rather than waiting until 2015.

5. The ARRA legislation and Meaningful use requirements could have been written to be more supportive of surgeons/specialists. Primary care was the principal focus but this left out the majority of clinicians. Even the activities of the regional extension centers are structured to facilitate the adoption of EHRs by priority primary care practitioners and federally supported health centers rather than surgeons and other specialists. I don't understand how this approach has promoted the goal of achieving coordination of care and a more cohesive health care system in this country. Although some workflows and documentation requirements are different for primary care than surgeon/specialists, there are still considerable benefits for adoption of health information technology by the latter. For example, structured order sets/care plans can increase efficiency, productivity and consistency of care. Surgeons/specialists recognize the benefits that evidence-based guidelines offer. Incorporation of evidence-based treatment recommendations into order sets is a mechanism to insure that guidelines are followed. Also, many types of clinicians are looking at the use of registries to enhance individual and population health. Consider the total joint replacement registries currently in use by orthopedic surgeons. Registries also facilitate identifying patients affected by recall of medical devices/implants. Finally, I am convinced that clinical decision support developments will significantly modify clinician approach to diagnosis and treatment across the spectrum of patients. Realistically, CDS is difficult without the adoption and installation of EHR technology in physician practices and hospitals. INFO buttons incorporated into EHR software are the future for content aware search capabilities for clinicians.