Being There for the Patients, Not the Bureaucrats

EHRs need to get smarter so we can spend more time with our patients

• by Fred N. Pelzman, MD
• September 28, 2018

What do our patients really want from us?

When a patient calls up to schedule an appointment, or sends us a message through the patient portal, or calls our front desk staff to leave a message, what is it that they're looking for?

I think, more than anything else, our patients are looking to us as healthcare providers to be able to be there for them, to address their health needs as broadly as possible.

I don't think that our patients want us to be automatons who are clicking boxes and satisfying mandatory required fields in the healthcare record for the sake of keeping insurance companies and government regulators and hospital bureaucracies happy.

Take, for instance, the requirement instituted for "high-risk" coding under Medicare -- documenting which patients have serious conditions such as diabetes or end-stage renal disease, which puts them at higher risk of bigger problems later on.

These mandates have been put into place by the federal government to help establish how sick our patients are, and to adjust reimbursements based on the number of health conditions a patient has.

Unfortunately, we as providers are suddenly required to report back all of the patient's healthcare conditions to the government to make sure we are being properly reimbursed for the care we provide.

A patient with a history of an amputation needs to have Medicare told that they had this amputation every single year, or else somehow the federal government is going to forget about this condition and dock our institution by lowering the rates they're reimbursed for their care.

Maintaining the Proper Focus

When my patient comes to see me, they want my attention focused on them, what's hurting them, helping them find the answers to the health questions they've come to me for, and they depend on me to provide them with the best counsel and management of their health conditions.

They don't actually think that my job in caring for them is to be a reporter of a bunch of bureaucratic tidbits back to their insurance company.

When patients become aware of these issues, such as when we're required to get prior authorization for an imaging study and we end up having to spend half an hour going through a complicated telephone tree and speaking to multiple people who don't know anything about the health condition the patient has, patients will say how sorry they feel for us and how it's a waste of our professional time; they wonder why someone else can't do this for us.

Perhaps if the patients' voices were loud enough, the people who've created the systems that impose all of this on healthcare providers would listen, since they are certainly not listening to us.

If patients (and maybe government bureaucrats) could walk a day in our shoes, and see all that we have to go through that isn't actual doctoring, then don't you think that they would demand whoever is doing this to us cease and desist?

Just as we want to focus on doctoring, putting those skills that we've worked so hard to perfect over many years in practice to benefit our patients, they want our attention focused on them.

They don't want us rushing through our office visits, staring at a computer screen, worrying if we have enough boxes checked off in the Review of Systems to bill a level 99214, have we fleshed out enough detail in the History of Present Illness questions to pass an audit, have we used the right templates and macros and smart phrases.

They want us listening, questioning, thinking, synthesizing, examining, probing, and putting it all together to get the big picture, to help them get to the best state of health they can be in.

Wouldn't It Be Nice?

Just the other day, a colleague of mine said to me, "If only I didn't have to touch that electronic health record (EHR) at all during the course of my practice session, I think I'd be able to take much better care of my patients."

Think of it, think of how easy would be, if all we had to do was walk into the room, greet our patients, sit down across from them, look them in their eyes, talk to them, hear what they have to say, dig a little deeper, then examine them as we saw fit, and then use what our brains have been trained to do to come up with a plan for how to take care of them.

Yes, there needs to be a chart, we need to have some documentation, and ultimately I do want what I found, what I thought about what was going on, what I put into motion as a plan to all be there for someone else to see, not really for medicolegal purposes, but more so others who follow the care of the patient after me can see what I was thinking, and help to further that patient's care.

We need to re-delegate the tasks that have been heaped onto our lives to more efficiently allow our whole team to practice up to their licenses.

A more patient-centered model of the office visit, if we admit that for now we might not be able to get a lot of this stuff, might look more like this:

When a patient arrives at the practice, there are an extraordinary number of things that can be done that shouldn't require the intervention of a physician. These include updating medication lists, inquiring about forms that need to be completed, completing a healthcare proxy, ordering age- and disease-appropriate health maintenance items, providing patient education, and ordering due vaccines.

A Smarter EHR

Shouldn't our EHR be smart enough to tell Medicare the patient hasn't been billed for end-stage renal disease or an amputation in the past year, since Medicare itself isn't smart enough to remember this?

And if everyone wants me to remember that a patient is due for their annual wellness visit that is covered by Medicare, but the patient doesn't mention that that's what they're there for, can't the system remind me?

It would be great if we could allow all of these systems to be built up around us, around the patient, to help preserve -- no, actually get back to -- the doctor-patient relationship we all value so much.

Sure, a note needs to be written, boxes need to be clicked, charts need to be neatened up and tucked away.

But in those precious few moments we have together, the patient and I, it should be more about letting us do some doctoring, truly being able to minister to their health, rather than trying to remember what initiatives are in vogue today, and satisfying some far-off auditor who has decided what they need to keep an eye on this week, this month, this year.

Someday, the computers are going to be smart enough that they will just be able to listen in on our office visit, and capture essential elements of what goes on in our history, physical exam, and medical decision-making. And the computer will click all the right buttons, order all the right tests, make sure everything is done to the satisfaction of the powers that be.

But for now, figuring out some ways to take some of this burden away from overworked providers would go a long way toward creating a healthier, happier set of physicians and patients.

That's what patients want, and so do we!