By John Carruthers, assistant editor, May 01, 2013
If there’s one constant to the practice of medicine, it’s change. The entire health system is undergoing an evolution that touches everything from record-keeping to the delivery of care. The practice of medicine today would be virtually unrecognizable to most doctors of the early 20th century. As the system adapts, so too have the tools that physicians have to deliver safer care to their patients. From smartphone-backed dermascopes and store-and-forward teledermatology to near-paperless offices designed for the flow of information and efficient visits, dermatology offices are integrating smarter solutions to enhance the practice of medicine in this time of change.
Evolving office efficiency
As the work of managing an office and, now, seeing a patient becomes increasingly digitally focused, physicians and practice managers now find that keeping apprised of technological innovation goes hand-in-hand with improving efficiency and innovating existing processes in their offices. Just the sheer reduction in paper around the office, according to Daniel M. Siegel, MD, the American Academy of Dermatology’s immediate past president, represents a sea change in the way physicians operate.
“We used to have lots and lots of paper that had to change hands for every patient visit. The linkage through EHR between registration, medical records, and billing is a big change,” Dr. Siegel said. “There’s a great deal of information flowing instantly from the front office to the provider, to the back office and billing department, and it can be done paperlessly.”
While the promise of instant patient lab data and seamless transition of records has yet to fully materialize, many physicians and office managers have found tools for efficiency in their EHR’s practice management features. Setting aside the actual visit between patients and physicians, Dr. Siegel said, the practice management capabilities of EHR have been effective enough to cause some physicians to take them for granted. [pagebreak]
“In the old days if I got a call from a patient, the staff would have to put the patient on hold, find the chart, and give the chart to me to review as I picked up the phone. Now it’s as simple as the staff saying Mr. Smith is on the phone,’ and I can sit at my computer and open the record before I pick up the phone so I can refresh my memory. I can see their records, their photographs, and their labs in an instant. That’s a major time saver.”
Looking forward, even the process of registering a patient electronically and checking them in for each visit can be made more efficient. According to dermatologist Jeffrey Benabio, MD, Kaiser Permanente’s director of physician innovation, achieving nearly-instantaneous registration through existing consumer technology is on the horizon.
“The next step forward is integrating consumer applications, like the ZocDoc appointment app, with your EHR. Patients already make appointments through this service and others like it on their computer or phone,” Dr. Benabio said. Such services are now working on the ability for patients to check in to their appointments via their apps, either by having the patient launch the app or having the phone detect the patient’s proximity to the doctor’s office where they have an appointment via GPS and starting the automated check-in process.
Automation of purely administrative processes, according to Dr. Benabio, is that rare feature of an EHR that both supporters and dissenters agree creates a clear benefit for both patients and physician offices. Some programs send automated text messages reminding patients of appointments; patients must agree to receive these messages first. [pagebreak]
Technology and the patient
While the integration of technology has grown in medical offices in recent years, it’s virtually blanketed the consumer sector. While social networking gets the most press, doctors have keenly felt the change as patients have more access than ever to information from all areas of medicine. The relationship between the doctor and the patient has permanently shifted, according to Dr. Siegel.
“Until very recently, you would give a patient a prescription, recommend a course of treatment, and the patient would leave,” Dr. Siegel said. “Now, if the patient has a family member in the room, by the time you’re done discussing the medication with the patient, they’ve already pulled up something on the Web about it. They have questions about the side effects and the costs. It’s almost instantaneous.”
The effect, he said, has unsettled some physicians — it creates a great deal of angst and serves to level the information playing field. But it can be argued that this patient engagement leads to tighter compliance and better outcomes.
Dr. Benabio agreed, saying that encouraging patient engagement and involvement is key for dermatologists going forward. Using technology — whether it’s electronic communication with patients, educational apps, or patient access to medical information — to connect with the patient empowers that patient to become proactive in their own care. [pagebreak]
One way Dr. Benabio recommended to harness technology was enhancing the visit for both parties with Web-based information. Several websites offer collections of medical images and information about skin conditions, accessible via smartphone or tablet, that dermatologists can use while engaging the patient during the visit and to provide valuable post-visit patient educational material. The AAD offers such a set of tools at www.aad.org/dermatologyatoz. It has also partnered with VisualDx to offer a clinical decision-support system that includes medical images that can be searched and used at the point of care; to learn more about the system, visit www.aad.org/visualdx.
“What the technology lets you do is actually show the patient a picture of, say, a granuloma annularae. So the patient says that does look just like me,’ and you follow that up by sending that information from the program to the patient electronically so that they can read about it when they get home,” Dr. Benabio said. “It creates a continuum from that episodic visit to the patient being able to access the information anytime and anywhere afterwards. It terms of being able to capture, keep, and forward useful information, it’s like medicine is finally catching up with fantasy baseball.”
Engaged patients with access to information, Dr. Benabio said, are far removed from patients of the past, whose opportunity for education started and ended at the conversation with the physician and their ability to remember it.
The previously unheard-of marriage between medical devices and consumer technology can help patients relate to their physicians better, according to practice manager and About.com patient service columnist Joy Hicks. It’s vital, however, for physicians to keep the focus on the benefit to the patient and be ready to explain or have their staff explain the function and benefits of new technologies. [pagebreak]
“Just like physicians, some patients are still afraid to go outside of what they’re used to doing. They’re also used to the traditional methods of treatment,” Hicks said. “When you can balance that one-on-one connection with the patient and the access to more information and better results, it’s the best outcome for both the patient and the doctor.”
The ability to aggregate, demonstrate, and forward patient and medical information to the patient in seconds can help coordination of care with not just the patient, but the patient’s caretakers and family. In achieving the best possible patient engagement, Dr. Benabio said, reaching out to not just the patient but their circle ensures that more of the message is retained.
“On the patient side, the active part of this process requires learning, and learning is hard. In the exam room, there’s often stress, and the patient may have a number of other distractions, so it’s not a conducive environment to learning,” Dr. Benabio said. “Someone might come in with a complicated problem, and they have to go home and relate that information to their spouse. If we’re able to use medical technology to share that information, you’re not engaging just the patient but also their whole caregiving network. It’s a great way to improve the quality of care that we’re giving.” [pagebreak]
Technology and the physician
On the physician side of things, medical devices that used to cost thousands and occupy a significant footprint are being shrunk down, piggybacked on to consumer technology devices, and continually re-developed. Dermascopes, for example, are now available as a palm-sized component that locks on to an iPhone and instantly transmits images into the medical record. The dermascope can be integrated with both the office’s record system and, for some, a HIPAA-compliant cloud-based photo storage system.
Ferdinand Mayer, the vice president for device maker FotoFinder Systems, says that his company’s decision to develop dermascopes for the mobile platform has changed a number of traditional processes for both the company and its clients.
“Our product was made possible by the fact that the camera technology on phones gets better and better with every generation. It’s actually quite the challenge to keep up,” Mayer said. “People get new phones every two years, and doctors always want the newest technology. We’re able to solicit feedback from our clients and respond to requests for new features — non-contact dermoscopy is one — in a much quicker time frame than with traditional devices.”
In addition, Mayer said, feedback from patients has suggested that in the future, applications built on the architecture of the Handyscope could be a useful tool for self-examinations, with that information sent automatically to a patient’s dermatologist and placed in the file for the next scheduled skin examination. [pagebreak]
Dr. Benabio goes further, suggesting that the current innovation may signal a shift of roles for physicians in the future. Extending the function of current groundbreaking technologies for instance, devices that help detect melanoma at ever-earlier stages could lead to software that would be able to assess and diagnose a melanoma with comparable accuracy to a physician. Further, that software could evolve into a handheld medical device or even a consumer device with surprising quickness.
“We could very well see that, which would fundamentally change what we do,” Dr. Benabio said. “Half of what we do is the diagnosis, and if we’re able to develop technologies that can do the diagnosis for us with a higher sensitivity and specificity than we can, then our role changes fundamentally. One day, diagnosis may not be our primary responsibility.”
For an online-only slideshow demonstrating one physician's foray into a patient-centered health app, click here.
A worldwide office
The true game-changer of the ongoing technological innovation in medicine, according to dermatologist Daniel M. Siegel, MD, is that where it used to be difficult to connect with patients, colleagues, and data outside of the office, it’s now far more difficult to disconnect.
“Getting untethered is the difficult part — we’re as tethered to our practices as we want to be,” Dr. Siegel said.
“I was on safari in Africa this past January, and when I got off the plane from London in Dar Es Salaam [Tanzania], I bought myself a SIM [subscriber identity module] card for my cell phone that came with a half gigabyte of data for $10. I’m sitting on the Serengeti in a place that wasn’t seen by Western civilization until a hundred and some odd years ago, and, when not looking at wild game, I’m getting email and text messages. Of course, that can be a good or a bad thing, depending on the moment.”
In addition to personal emails and text messages, Dr. Siegel said that through the features available on tablets, smartphones, and the like, he has the ability to access and manage patient information anywhere in the world. He does, however, prefer to limit his off-hours use.
The spread of cheap, reliable cellular network data, according to dermascope company executive Ferdinand Mayer, opens the door for even greater applications for dermatologists in underserved and remote nations. As technology shrinks and becomes far more user-friendly, he said, the expertise of a specialist can be made to spread farther afield than was imagined just 10 years ago.
“We began the project of developing the mobile dermascope based on demand from a lot of places where dermoscopy is not as developed as it is in Europe and the U.S. There are places where the information technology architecture cannot and will not be able to afford the opportunity to purchase and use a traditional medical device like a dermascope,” Mayer said. “Where we hit limitations on the abilities of the phone, we can create cloud-based solutions. The opportunity to engage primary care physicians both in the country and abroad is clear.”
Engaging with patients via technology is not just a good idea for improving outcomes, as discussed by Daniel Siegel, MD, and Jeffrey Benabio, MD, above. It is also a component of the meaningful use requirements for electronic health records. When stage 2 reporting requirements take effect, they will require physicians to:
- Offer secure electronic messaging (i.e. secure email) to communicate health information to patients. This could include lab results or a list of current medications.
- Provide patients the means the view, download, and transmit their health information within four days of the information’s availability through a secure online portal. Half of all patients must be given access; 5 percent must take some sort of action, by viewing or downloading information or electronically transmitting questions or information.
More information about meaningful use requirements appeared in the February Dermatology World Technically Speaking column and is available at www.aad.org/monthly-archives/2013/february/meaningful-use-reporting.
Online-only slideshow: Patient-centered app
A cardiologist's app for patients is demonstrated in an online-only slideshow.