Tuesday, May 8, 2007

E-Medicine, Consumer-Driven Care, Only Patients Will Change Health Care

Only Patients Will Change Health Care

”Engaging ” Patients" and “Structuring” the Patient Interview

By Allen R. Wenner, M.D.

Prelude by Richard L. Reece, MD: About seven years ago, Drs. Allen Wenner , Donald Copeland, John Bachman, and I formed an organization called the High Performance Physician Institute. The idea behind it was to teach doctors to use electronic medical records to change how they practiced medicine. We focused on how to use a piece of software called the Instant Medical History. This software permits patients to take control of their care by creating their own history based on what they perceive to be their problem. In other words, it “engages” them to tell their story from their point of view without being interrupted by the physician.

The software is easy for patient to use, usually takes less than 10 minutes of the patient’s time, consists of ‘yes” or “no” clinical algorithms based on patients complaint, age, and gender; and eventuates as a narrative history given to the doctor before the patient enters the exam room. This process saves time, results in a more standardized, more accurate patient, and allows the patient to leave the office with a complete medical record containing the patient’s history as told from their point of view, the doctor’s findings, and the treatment plan.

Moreover, it is accurate, has the ATM-like virtue of making data entry free, possesses that sought after attribute known as “transparency,” lessens misunderstanding about what transpired , thereby reducing risk of malpractice, and, best of all, “standardizes” what takes place between doctors and patients, making it possible to measure and compare quality and outcomes from a common base.

Patients leaving their doctor visit with their EMR in hand has become known as Bachman’s Law. John Bachman is professor of primary care at the Mayo Clinic in Rochester. Allen Wenner, who created the Instant Medical Record 15 years ago, and Dr. Bachman have been on the lecture circuit as a dynamic duo for over 10 years. They seek to change the basis of patient-doctor interaction. As Allen indicates below, and in a chapter and case study in my book Innovation-Driven Care, physicians resist the power shift to patients in the doctor-power relationship. Read closely what Allen has to stay. It is profound.

Here is an essay written by Allen Wenner, still in active practice as a family physician in Columbia, South Carolina, and a sought after speaker on the EMR circuit.

Doctors in Control

When will health care change from a physician-centric world to a patient-centered world? For three thousand years doctors have been in control of medicine. Doctors tell you when to come to see them. Doctors make you to wait until their determined time to see them. If you don't like it, you can come back tomorrow. Doctors decide what information you will impart to them. Doctors ask you the questions they want you to answer and they decide what the diagnosis is. Doctors determine the treatment.

No Standards for Patient Interviewing

There are no required minimum standards for patient interviewing. In other words all doctors use different data from the patient.

There no accepted guidelines for diagnostic acumen. Ten doctors can give ten different opinions about the same patient. None could be right, some could be partially right, or all could be right because it would not make any difference.

How do you as the patient know? Studies show that doctors make errors 24% of the time when they see you because there is no agreement about what quality is. Quality is unknown because nothing is measured in a structured way in individual medical encounters.

Physicians tell you what to take and when to take it. If you don't take it, can't take it, or take it and don’t get better, they tell you why it is your fault that you are not well. This is a doctor-centered world. Basically, the doctor centered world is a belief systemthat medical opinion is fact. It is nice to be a doctor in that world.

The Internet Changes the Landscape

Information technology, especially the internet, changes the landscape. No longer is knowledge the sole possession of the doctor. Digital information is transparent to all. The patient may have more information than the physician about a given condition. The physician certainly offers experience in therapeutics.

That experience will increasingly need to be based on evidence, not a belief system based on unsubstantiated opinion. Information empowers the patient to be an active participant in care, if he/she chooses. Since it is the patient’s health that is at stake, greater patient involvement seems a reasonable guess about the future for medicine.

Dr. Larry Weed, father of modern medical charting, asks why a pilot on an airplane always performs a routine checklist outside and inside the aircraft before every take-off while a doctor does not complete a routine checklist during a medical history of a patient. His answer, “the pilot is on the plane (and the doctor isn’t).” Patients are the most interested in quality of care.

Patient-Generated Medical History Part of Patient Revolution

Instant Medical History is but one part of this knowledge and patient revolution in health care. With Instant Medical History, the patient decides what the complaints are. The patient sets the agenda for the interaction. The patient decides all the symptoms and problems that he/she wants to address with the physician.

The physician gets all the information that the patient thinks is important. With Instant Medical History the patient is not cut off after 20 seconds by the doctor. The doctor is forced to acknowledge all the patient's concerns. It is not that doctors don’t know what to do, it is that often they do not have all the data.

Using Instant Medical History the patient will give the doctor more information. If all the information from the patient is available, then a reasonable case could be made that outcomes will be better. No one really knows if medicine can improve because health care is not currently measured with any reproducible discrete, digital, searchable data model. Medical care today is based to a significant degree simply on opinion. Information technology facilitates measurement of quality at levels that are frightening to physicians.

Ambiguous Medical Records

Medical records as recorded today are ambiguous. How can the same patient go to three different doctors’ offices and have medical records that are totally different? A close examination of the process reveals the vagueness of the documentation. The receptionist takes the patient complaint. She interprets that complaint to the physician’s assistant or nurse that will triage the patient to decide acuity of care. The bias shown by these interviewers will be reflected in the verbal and written documents presented to the physician. Different physicians will approach the patient differently. Their medical records will reflect the differences in approach for the same presenting complaint.

An Example of Ambiguity

For example, let’s consider a 45 year old male patient presenting with intermittent right upper quadrant abdominal pain of several weeks duration.

• The patient could present to one physician who might ask if the pain ever occurs with activity. A vague or uncertain answer could initiate a cardiovascular evaluation for atypical angina that would be substantiated by the records.
• A second physician could ask the patient if it occurred at night. That evaluation could lead to an ultrasound of the gall bladder which might reveal gall stones. We know that more gall stones are found at autopsy than at surgery, so the significance of the finding becomes opinion, based and substantiated by the medical record.
• A third physician might begin with questions about heartburn that could lead to a diagnosis of reflux esophagitis. In all three cases, the medical records for the same patient will be dramatically dissimilar.

This variation makes analysis of outcomes totally arbitrary. Until we have the input from the patient, no standardization of data or measurement of outcomes can occur.

Physicians Resist Patient Empowerment

The reason nothing has been done to move patient empowerment forward is this resistance to change. Why would physicians support change that represents a loss of control? The Luddites of the Industrial Revolution destroyed textile factories in England two hundred years ago because they feared losing their jobs to the machine weaving looms. Physicians see Instant Medical History and fear it will replace them. It took doctors 40 years to accept the telephone as a valuable adjunct to patient care. Are physicians like the Luddites of the early 21st Century?

Physician Paternalism is A Problem

Patients have facilitated the status quo of physician paternalism. Three decades ago patients in the UK commonly received chemotherapy from physicians with horrific side effects and were never told that they had cancer. The patients have simply and blindly their trusted physician to do the right thing for them. Only two decades ago patients needed a court order for access to their own medical records in the some parts of the United States. Should we be surprised by the lack of progress toward digital medicine?

Transformation in Health Care Must Come from External Forces

It will never come from inside institutions like medicine. I have been lecturing for 15 years on changing health care and improving health care quality. I upset some doctors, entertain many, but always get flattering reviews of my presentations on use of information systems to improve quality in health care. New ideas in medicine are interesting, but are never adopted quickly.

The discovery of surgical antisepsis by Semmelweis took decades for acceptance by physicians. His observations went against the current scientific opinion of the time, which blamed diseases on an imbalance of the humours in the body. The Semmelweis Reflex is the dismissing, discrediting, ignoring, or rejecting out of hand any idea or information, automatically, without thought, inspection, or experiment.

The editor of one of the most prominent peer-reviewed journals of medicine in the United States considers information technology, medical error evaluation, and electronic medicine all to be a pseudo-science, not the pure hard medical research for stamping out disease. That attitude perpetuates a medical establishment that is quite happy with the status quo.

By using medical jargon, offering obtuse opinions, and perpetuating a belief system, doctors will remain in charge of the health care system. Issues about compliance, patient empowerment, and health care outcomes are thought by most physicians to be the venue of sociologists and politicians, not medicine.

Only Patients Can Change Health Care

Few physicians change their basic attitudes and behaviors because changing a culture based on a belief system is hard. The excellent review of impact of technology on institutions is based on a series of lectures by Harvard business professor, Elting E. Morison, Men, Machines & Modern Times. External forces will have to modify health care. Only patients can bring revolution to medicine.

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