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How Innovation in healthcare means going against entrenched beliefs about the nature of charting

American Medicine is in an unprecedented crisis. Doctors are not happy. A recent study by the AMA shows that physicians are spending twice as much time with their Electronic Healthcare Records (EHRs) as they are in “direct clinical face-time” with their patients. The study also revealed widespread career dissatisfaction among physicians with 54% reporting “physician burnout.”  Doctors are wasting hours a day struggling with their computers to document medicine and provide care to patients with whom they spend less time every day.  Patients feel their doctor is more concerned with data on the computer than listening to their problems and caring for their needs.  Meanwhile, health care costs are climbing while providers are getting progressively more frustrated at playing data entry clerks.
Remarkably, computers were first introduced to the examination room precisely to resolve the chaos that clinicians faced with paper. Initially, computers promised to make documentation easier and more effective. Instead, EHRs severely worsened an admittedly a bad situation.  What is even stranger is that in all other fields of endeavor except medicine, information technology has been highly successful in streamlining paperwork and bureaucratic congestion. Why has this not happened in healthcare?
One strange explanation propounded many in the IT field is that doctors are “computer-phobic,” that physicians fear technology and lack the adequate technical skills to handle computers.  Nothing could be further from the truth.   Physicians are highly-trained in the sciences and have used every new technology appearing in the medical field effectively for at least a hundred years.  Other pundits argue that physicians are reticent to change and are stuck in their ways. That’s not true either. Doctors are more likely to embrace new approaches than any other profession. The answer must be looked for within the charting software itself. Yet, EHR software precisely replicates the paper charting methodology used for over a century.  Maybe that’s the problem. Innovation has not challenged entrenched beliefs in the old paper method of charting. The old paper paradigm remains bound to the past: an electronic typewriter regurgitating text inside a dead record.
The problem seems to be not with the computer but with the original paper record. Charting on paper never worked well even before the first computer ever saw the light of day in a doctor’s office.  Indeed, the charting paradigm had been malfunctioning for at least thirty years, ever since the old three-by-five cards, used for more than a century to remind clinicians of the patient conditions, were replaced by reams paperwork as a response to the medical malpractice litigation beginning in the sixties.  Then, with stacks of medical paper records filed and stacked up to the ceiling, third-party payers, particularly the government, began to use this paper as criteria for denial of payment for services rendered.  So what was written on the medical record became more important than what was done.  And no one questioned the paper approach.  As lawyers put it, “res ipsa loquitor” (the thing speaks for itself), meaning: “if it’s not written, it’s not done!”.  Sadly, today’s physician can earn more by spending five minutes with the patient and twenty minutes with the chart, than by spending twenty minutes with the patient and five minutes with the chart.  Clearly, there is something profoundly wrong with this charting approach.
So why did medical software developers maintained the old charting paradigm in their EHRs instead of giving careful thought to take advantage of the unique power of the computer to handle routines better than humans can?  The answer is simple. No one wanted to challenge physicians’ entrenched beliefs that the current way of charting is the only valid approach.  Consequently, programmers worked on the wrong premise from the start and, by porting it to the computer, they made it far worse. The argument was simple:  “It had always been done this way.” Except it wasn’t. Charting the essence of a clinical visit on a three-by-five-card, as used by our forebears, is not the same as a computer spitting out tons if complex computer codes to explain a clinical encounter only because computers cannot handle human language.
Indeed, after the initial CPT and ICD-9 codes developed by the AMA and the World Health Organization to describe acceptable treatments and diagnoses, an array of new codes appeared on the scene: G-Codes, F-Codes, RxNorm codes, LOINC Codes, SNOMED codes, the list seems endless.  These codes created havoc for busy practitioners who have turned into data-entry clerks of a sort, wasting time and creating stress and confusion, which can lead to clinical errors. SNOMED, in particular, is meant to describe the entire medical exchange: the patient symptoms, the clinical findings, the diagnoses and all the treatments in “computerese” rather than English, and drives doctors completely crazy in the process.  Even a new medical syndrome is being recognized as affecting healthcare providers called the “Alert Fatigue Syndrome.”  Now, the law of the land is that doctors are to search all these codes to transmit clinical information to their peers. No one stopped this insanity and realized that we had the basics wrong.
So then how should busy clinicians document their clinical exchanges if not the way they were taught for the last two hundred years? We, at Praxis Electronic Medical Records, believe the answer is for the computer to help the providers think and express themselves using their own thoughts and words by retrieving them just in time from an artificial intelligence database so as to learn from their own past encounters of similar patients. As we like to say: “It’s faster, easier, and better to do what you wrote than to write what you did.” Charting backwards? You bet! This is not what physicians were taught to do, but then again, our forebears did not have computers to assist them in the examining room, nor reams of data to fill out, nor attorneys and third-party payers to deal with. They did not need to chart up a storm to be able practice medicine.  The chart then becomes, not a silly compilation of what is being observed over and over again, but an actual living checklist that ensures than nothing is forgotten or overlooked at the point of care, that all the questions are being asked, all the relevant findings and studies are being evaluated, and yes, it also charts instantly so saves about two hours a day.
It seems that doctors had the basics wrong from the start. If the goal is to practice higher quality medicine by taking better care of patients, paperwork should not get in the way. On the contrary, documentation should assist the thought process, guide it along, and not hinder it. The computer can do that if it is programmed appropriately.
The concept processing solution works. It has been used for several years. Praxis EMR is consistently rated number one in physician user satisfaction studies performed by the largest medical organizations today, including the American Academy of Family Physicians the American College of Physicians, yet few know why Praxis scores so highly. Indeed, this new charting approach goes against the grain.  It fights against entrenched beliefs about the nature of documenting medicine. Often for a major change to take place two things are needed.  Technology must represent disruptive innovation, and there has to be a lot of pain with the way things had been done up to that point. The latter is already here among physicians. Doctors today must heal themselves.
About the Author
Richard Low, MD of Praxis® Electronic Medical Records, is one of a handful of physician CEOs running EHR companies. A graduate from Yale Medical School and practiced both Emergency Medicine and Internal Medicine for more than 20 years. Doctor Richard started the company in 1989 to resolve the main problem with charting, precious time being wasted by providers. By learning from hundreds of medical clients throughout the years, Praxis is today more than just an EHR, it is a clinical tool that enables doctors to provide better medicine, save time and reduce professional stress and burnout.