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Building the Patient-Centered Medical Home: Making Changes that Count

By Fred N. Pelzman, M.D.

Originally published by MedPage Today

Shouldn't we be able to get things how we want them?

While this may sound a little petulant, and can probably be extended to almost everything we have been asking for in terms of changes in the healthcare system in this country, I'm speaking today specifically about the electronic health record.

Years ago, when doctors first started keeping records on their interactions with patients, if some administrator somewhere had told us that we had to use cuneiform styluses on clay tablets to keep our records, wouldn't we have rebelled? Would we have stood up and said, wait a minute, paper and pen might work better?

And by the way, not only are clay tablets a bad idea, but we have some ideas about how to build this so it helps us care for patients. We need a section to list their medications, a way to flag their chart that shows they are allergic to a certain medicine, so that we don't end up giving it to them, and a separate section for the paper copy of their lab results to get filed once they finally make it over to us from the lab.

Things have changed drastically and dramatically since then. We now have these massive computerized systems that are theoretically designed to stand as a record of our interaction with our patients.

For the most part, we dutifully document along, typing in our HPI, filling out or clicking all the boxes for medical history, surgical history, social history, medications, allergies, family history, review of systems, physical exam, and then finally getting back to some more actual typing and thinking with our assessment and plan.

What we've learned, however, is that most of these electronic health records weren't created by doctors taking care of patients. They were created to build a document that can be easily routed on to be checked for billing potential and regulatory compliance.

Despite some grumbling, we've been able to muddle along through the years, as these products have grown from simple word processors to sophisticated relational databases that allow us to do many incredible things that actually help keep our patients safe, and better document what happened in the office.

Unfortunately, it also allows us to easily dump in every lab that has ever been run on a patient, or template massive detailed physical exams that inadvertently let you click that someone's body part was normal when they don't even own that body part.

And now, more and more, we are being asked to do more and more with these electronic systems. We are being asked to be compliant with multiple guidelines, measures, recommendations, regulatory standards, that come at us in wave after wave of boxes to click.

Yes, we think that ensuring that a medication list is accurate and clicking the box saying that we say it is, it's a good thing.

And yes, including pain as a mandatory vital sign has, for the most part, helped us improve the care of the pain our patients are suffering from.

But then we get endless more boxes that we have to click for Meaningful Use, Accountable Care Organization, Joint Commission standards, and on and on and on.

Unfortunately, the requests for these new functionalities get placed in the system and come to us as a fait accompli for us to complete, something we just need to click and be quiet about.

When we complain, and say that just asking doctors to click a lot more boxes really doesn't help us take better care of our patients, we are told that this is the way the functionality exists within the electronic health record, and we just have to live with it.

When I click the box that says my patient has fallen and injured themselves once within the past 12 months, and I have a plan to try and prevent this happening again, with three simple clicks of some buttons I am compliant with this recommendation. The information gets sent to a big database somewhere, and it helps our numbers.

But does it help our patients?

After I click "Yes, the patient has fallen," up pops, "What are you going to do about it?" There are several options, including change the patient's medications, send them to physical therapy, do a home safety assessment, and then an open text box to type in whatever else you thought of to keep that patient as vertical as possible.

But these boxes are not "live," they don't lead to an action, so I can click them and say that something happened when, in fact, nothing did.

This is exactly what we don't want the new electronic health record to be as we move forward into 21st-century healthcare. I do worry that my patient has fallen, that their blood pressure is high, that their BMI is way too high or too low, and I want to do something about it, but if all I'm doing is clicking a box to improve the percentage on some annual report, there is nothing to ensure that change will actually occur, that the patient will actually fall less as a result of this.

We've asked that the action of clicking the box that says I'm going to send this patient to physical therapy will actually place an order for physical therapy.

Makes sense, right?

Apparently, it can't be done.

We, the providers who are taking care of real patients, the ones who have the highest probability of being able to think thoughtfully about functionality and getting our patients the care they need, should be holding the controls on what the EHR can and should do, and call the shots for change.

If we think something should be changed so that it works this way, why do the people who currently do control the electronic health record say, "That's too expensive; that's not the way it's done; we can't change it"?

Would lawyers or bankers accept this about the systems they depend on to do their jobs?

And while there are lots of things out there in the healthcare landscape that we have found get in the way of caring for patients, and there are dramatic changes we need to make over the coming years, this is one instance where it makes sense that the decision-making fall into our hands, not someone else's.

I will click on the box that says my patient has had a depressed mood for the past two weeks, and will then dutifully do a further assessment of their depression, but then make it easy for me to get the patient to the mental health care they need.

Or better yet, let the technician who brings the patient to the room ask the PHQ-2 screening questions, and if positive let my nurse administer the PHQ-9, and if that is positive then route it to me so that I can assess them, and give me a psychiatrist who can see them that same day if we uncover an urgent need.

As we extend the patient-centered medical home model beyond the walls of our office, blood pressure and BMI beyond the recommended ranges should automatically take them to a community health worker who will help them find a gym where they can exercise, and keep pestering them to make sure they go, and help them find healthy affordable food choices in their neighborhood to help lower their blood pressure and their weight.

If not, we will end up with a lot of clicked boxes, some really good scorecards, and patients no healthier for all that effort.

Then we may as well go back to clay tablets.

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