I’ve seen it in a variety of practices, my own being no exception.
Free texting to document a patient encounter.
You’ve got your clickers, the orientation spiel goes, and ya got your typers.
Me, I’m a typer, but the system allows you to document any way you like. To each his own, and I love the look of my own text!
So, when your IT folks suggest that you align yourself with the clicker column, so to speak, you might find yourself getting a mite…testy. Vocally belligerent, even — it’s a free country, and I’ll free text, doggone it.
What follows are some thoughts about why you might want to reconsider. Reeeally reconsider…
“Join Or Die”
America’s first political cartoonist, Benjamin Franklin, penned the following image, encouraging the colonies to pull together, during the French and Indian War:
A bit ominous, granted, but you get the drift. United we stand, divided we fall. And if you’re curious, the officially sanctioned “EMR cause” to join these days is discrete data entry — button clicking.
Free texting is that squirrelly separatist inclination that weakens everyone, in the face of hostile forces. Which makes sense from a strategic perspective: everyone proudly doing their own thing with a disdain for documenting consistency, can’t be good from a unity standpoint.
But in this case, the enemy isn’t France and its agents on the 18th century frontier — and if you want to text freely, the enemy isn’t your EMR vendor, either.
It’d be easier for them to make an EMR into a big, free-text machine (they’re called “word processors”), and infinitely harder to make it into the interlocking databases that true EMR’s are. Keeping track of button clicks and cross referencing list choices must be planned out in advance, with tons of user input and testing. If it’d get the job done, EMR vendors would be ecstatic at doing away with all that data juggling, and letting doctors type, cut, copy, and paste on blank screens.
Collectively, the “enemy” of free texting your entire note is any and all forces that make discrete data tracking a necessity. I’ll come back to that in a bit, but for now, remember:
Lesson #1: There’s a wolf at the door, and much as we’d like to blame the establishment, it’s NOT the EMR vendor.
So Big Vendor’s Our Friend, Eh?
You’d better believe it.
Keep in mind that any business, especially a moderately big one, will prefer to keep its internal processes simple, and its customers happy.
In EMR Vendorland, the current trend is towards button clicks and list choices, despite the fact that
- doing so involves much more programming complexity, and
- loads of physicians, especially from small groups or solo provider offices, want free texting
Better yet, this same group loves text macros — small programs that can run in parallel with EMR software, enabling sentences or paragraphs of a doctor’s own text to be recalled and inserted with a few keystrokes.
So are EMR vendors purposefully peeing into the wind? Doubtful, or they won’t be around for long.
Lesson #2: The EMR vendor wants to keep you a happy, faithful customer; there’s a reason for the apparent paradox in not recommending free text, everywhere for ever and ever, amen.
So What’s More Important Than Market Share?
And quite a slice of the marketing pie it is.
According to the National Ambulatory Medical Care Survey in 2003, 38.5% of physician practices are solo practices, with 73.1% of all patient visits occurring to doctors offices with 4 or fewer providers — and more than half of those visits are to solo practitioners’ offices.
And pardon me for saying so, but there’s a certain correlation between small/solo practices and wanting to document freely. You can’t make it in a small private practice without singing “My Way” in the shower all through med school.
Put 2 and 2 together, and you’ve got a lot doctors and patient visits potentially leaning towards the free texting movement. As in, “2 out of 5″ practices, and “7 out of 10 patient visits.”
If EMR vendors aren’t aware of this math, and are deliberately pissing off folk who may prefer documenting their own way, that’s a pretty suicidal business strategy.
UNLESS…there’s something more detrimental to the vendors’ future than pissy small or solo group customers.
Lesson #3: If the healthcare system itself tanks, we’re all going down.
“I’ll Kill You Later”
I’ve alluded to better and brighter minds than mine in a previous post. Apparently, the new Health & Human Services Secretary, Tom Daschle, and President-elect Obama are among them: EMR’s are figuring universally in any major plan to fix the American Health Care system.
My understanding of this is evolving, but in a nutshell, whether fatally broken or just really badly in need of repair, you need accountability to have a hope in heck of fixing the system. Meaning, track what is going where, how much it costs, what your outcomes are, and how long it takes you to get there. Get a baseline, tweak, reassess, and repeat.
THAT’s the basic, iterative mechanism that is coming (and It Cometh On Like Gangbusters):
- What’s your specialty’s average “score” at treating Condition X?
- How does your particular practice measure up?
- What are your competitors’ scores?
- How do they compare on cost?
- How do they compare on convenience?
- Why should patients come to you if your overall measures are lower?
You see where this is heading?
Re-rank the following, in order of overall significance:
- Survival of the entire healthcare system
- Survival of your practice within it
- Your insistence that “ctrl-U” spits forth your personal Urinary Tract Infection protocol on the progress note
Lesson #4: Time to get our heads out of the sand — we can argue documenting convenience later, but we will need stats and numbers to fight with real soon. For the survival of our practices, as well as the system, itself.
Youcandoitthehardway…
Or you. Can. Do. It. The. Easy. Way.
Believe me, you’ll want to do it the easy way, because “it” is going to mean combing through the data of your practice, your region, maybe even your specialty, not just for one medical outcome, but many, and not just once, but periodically, on demand, as your practice and patient demographic changes.
Again, this is the Iceman that is coming. THIS is the wolf at the door: assessing, improving, and justifying your practice’s data. It won’t matter whether it’s for your medical director, your IPA, an insurance carrier, or a government agency — data mining is as inexorable as an avalanche, and as such, you don’t argue with it, you just deal with it.
Free text strings are gobbledygook to computers. The most beautifully worded, stylistically perfect text paragraph is just one long ream of alphanumeric characters to a computer. Meaningless, so far as data mining goes, like a string of Attic Greek characters with no spaces in between.
That’s nonsense, you say, I can run a search on my text heavy records, by specifying a search string! I always use “A1c” when referring to my diabetics’ glycohemoglobin, and I always put it in field 271 on the progress note! Don’t tell me my EMR can’t accommodate my particular free texting when it comes to running reports on my diabetics!
That’s great, really it is.
What about your partner? Or your other local colleagues, or your group as a whole? Are all of them using “A1c,” or or some of them using “HbA1c,” or “a1C?” Maybe some of them put the value in field 271, but others don’t enter it at all, it’s entered automatically into the lab module via a lab interface, on page 2, field 37(b).
Your report generating strategy takes a geometric leap upwards in complexity, the minute you step out of your own practice. Why can’t different EMR’s consistently talk to one another? Sheesh, why can’t individual doctors document in the same way?
It’s Like The Jim Croce Song
Listen to a copy, if you can find one; it’s a cutie:
You don’t tug on Superman’s cape.
You don’t spit…into the wind.
You don’t pull…the mask off the old Lone Ranger,
And you don’t mess around with Jim.
Lord knows, solo and small group providers fight the good fight, every day. And not all such doctors resist “documenting digitally,” as I put it, i.e. with discrete data clicks.
But as anyone in the industry knows, it’s a recurrent phenomenon, and a recurrent refrain:
I want to document in the free text blank spaces, I want to copy and paste previous just-so notes, and I want to do so everywhere — history, exam, plan, all at once, preferably.
That impulse is understandable; it’s behind some vendors’ efforts to create “do it once, remember it forever” options for saving and re-using favorite pages.
But too often, there’s another impulse on the heels of that one: I could care less about data mining, or defending myself in case of a chart audit, or making it easy to compare my “numbers” with my peers’. Less, in other words, about any concern but my own documenting speed and ease.
Newsflash: if you count yourself among this group, the days when speed and ease were your biggest worry are OVER.
There’s a reason for going along with clicks, and it’s spelled D-A-T-A. With it, you and your fellows can go toe-to-toe with The Wolf, The Iceman, Jim, and his successor, Slim.
Just Click and Save, boys. Just Click and Save.
