By Warren R. Heymann, MD, December 02, 2013
“Dr. Heymann, if you were 20 years younger you would have had that note finished by now.”
“Mrs. Falcone, if I was 10 years older, I’d be OUTTA HERE!” (With all due respect to the late Phillies broadcaster Harry Kalas).
Since childhood, I have been told that the golden age of medicine has disappeared. When I was 10 years old (in 1965) I recall the grumblings of our general practitioner that socialized medicine would destroy American medicine. From the time I graduated medical school in 1979, the progression of DRGs, capitation, PPOs, HMOs, CLIA, HIPAA, RACs, and currently the ACA (Obamacare), has provided a relentless drumbeat of administrative dictates making me wonder if I would have the wherewithal to survive.
Of all the transitions, however, only the implementation of electronic health records was accompanied by foreboding dread. Why? I learned how to type in Mrs. McManus’ 7th grade class, graduated from a Royal typewriter to the Smith Corona electric to a word processor to Word Perfect to Word and from PC to Mac to iPad. I know I will never be as proficient as a toddler breastfed on electronics, but for someone my age, I am not a Luddite.
Regardless, the fear was real, yet the time had come to switch. There were obvious reasons to do so — get whatever monetary incentive Obamacare would allow and avoid the penalties of delayed implementation. Perhaps it may not make economic sense for an older physician in solo practice considering retirement in the near future. As part of a group (as the senior member) there really was no choice. EHR is the future and there is no going back. What tipped the balance for me, however, was a simpler reason — I had to admit that my handwriting had gotten so awful that even I could not translate it. [pagebreak]
Our program is iPad-based, and although not completely intuitive, reasonably easy to learn. I have now used it for approximately two months, and have become more facile with it. Admittedly, the first couple of days were harrowing, despite cutting our schedules in half and having an expert in the program guide us through the process (following 20 hours of lessons prior to going live). While I do not believe that I will ever see quite the same number of patients that I have in the past, I can attest that there are distinct advantages: 1) the electronic prescribing is a delight; 2) photodocumentation with the iPad is a pleasure; 3) finding patient data and writing notes on patients when on call away from the office is painless; 4) being confident about proper documentation for the level of service billed, thereby avoiding undercoding for more difficult cases; and 5) being able to read what transpired.
I am still working on what I perceive is the biggest disadvantage — the new paradigm of the doctor-patient-iPad, instead of the classical doctor-patient relationship. Fortunately, most patients are very accepting of this as they are experiencing this phenomenon with all their physicians. I have found the best way to handle this is to turn around and show them what I am doing and how the note looks — most are quite impressed!
Being patient was never my forte; I thought this might improve with age, but it has not. With paper charts, if you are running behind, you could take a few shortcuts on your notes using some acronyms or symbols — no longer. Should your pen run out of ink, you would just reach in your pocket for another pen — now when the “cloud” is taking its time to respond, and the iPad says “saving,” which seems to go on in perpetuity, all you can do is look to the heavens (isn’t that where the “cloud” is located?) and pray that the system does not crash. While it may only be for a moment or so, those minutes add up — 10 or 15 “absence seizures” a day not only equates to lost patient revenue, but, more importantly, puts you further behind schedule. I understand that perception is reality; I recall spending hours in the medical school library, in the stacks with Index Medicus, striving to find the right article. Now, if it takes me more than three milliseconds to do my research on PubMed I have a fit. Having become accustomed to instant information gratification, any aberration in that process seems like an eternity. [pagebreak]
Even if you become enamored and capable with your EHR, it does not mean that the front desk and nursing staff share your enthusiasm and ability. Even though everyone in our practice started together, it certainly did not mean that we all advanced at the same pace. Here is where my impatience has also gotten the better of me — this has led to periodic undue stress as so many issues regarding patient flow came to the fore. Constant vigilance and a willingness for all the staff (especially me) to be flexible to new approaches in handling patient reports, laboratory data, and electronic prescriptions were absolutely necessary to make the system work.
A final paradox — only rarely did I ever re-read my handwritten notes to make sure there were no glaring grammatical or spelling errors. Now when I find such errors in my notes, it really galls me. Maybe this has to do with my years of editing. Perhaps because of the clear legibility of EHR, I feel compelled to get it right. For someone with compulsive tendencies, this has the potential to drive you insane! As I am writing this essay during the Jewish High Holidays — a time of introspection — I am trying to convince myself that I need not be so particular when it comes to such errors. Alternatively, it is all too easy to have genuine substantive errors in the note if you click on the wrong template, or do not modify the correct template — one has to be alert!
So yes, fellow senior dermatologists, I am surviving. The EHR will get better and so will I, at least until the implementation of ICD-10!