Philip Bain knows what he really wants from health IT: “I want an individualized, life-long, evidence-based care plan for each patient that’s visible to all members of the care team including the patient, that’s available any time, especially whenever the patient interacts with the care system.”
Calling it “the Holy Grail of primary care,” Bain says “we aren’t there yet.” He has a lot more ideas about what health IT could and should do. His frustrations about its current limitations reflect both his impatience to further improve care and outcomes, and the relatively primitive state of health IT currently compared to other industries. For example, says Bain, “Walmart has used bar coding for inventory control for decades, but this is still unheard of in medicine.”
Bain is an internist in Madison, Wisconsin, practicing with Dean Clinic, a 700-physician practice. He serves as the site chief of the system’s East Clinic Internal Medicine Department, which achieved NCQA Level III accreditation for being a Patient Centered Medical Home in 2012.
Do The Right Thing, And Don’t Do The Wrong Thing
The Clinic has been using a well-established electronic medical record system for nearly 10 years, says Bain, and he appreciates what it offers. “We have very good integration of information with the hospital, laboratory and medical imaging departments as well as subspeciality care,” he says.
“For example, last night a patient of mine was seen in the emergency room. I came in this morning and all the information was available to me: what tests were done, what the results were, what the discharge diagnoses were and what discharge instructions were given. I typically forward this information to my nurse and ask her to contact the patient for an update on their condition and to schedule a follow-up visit with me if necessary.”
“The EMR collates the data,” he says, “and compartmentalizes information so you can find things quickly and compare them over time easily. With all of the data from past medical records, labs, x-rays, and hospitalizations readily available, you can get a pretty accurate view of what’s up with the patient in a short period of time.” He can even look at actual x-rays using the PACS system, he says.
Better Patient Engagement
In addition to housing large amounts of data, the EMR can also provide point-of-care decision support to help the clinician make better decisions. “The goal for an EMR is to make doing the right thing really easy, and make doing the wrong thing really difficult,” says Bain. For example, pop-ups that remind him when screenings are due or warn about drug interactions help Bain practice more evidenced-based medicine.
He also notes that the EMR can significantly improve patient engagement. For example, the patient portal, which gives patients access to lab and x-ray results, medication lists and recommended screening tests, gets patients more actively involved in their care.
The portal also allows patients to communicate with their care team in a secure way to ask for medication refills, get results and ask medical questions. Bain says he finds it particularly gratifying when patients are clearly engaged in their care. “I love it when a patient emails us and asks, ‘Aren’t I due for a colonoscopy? If so, can we set it up?’” he says.
Bain says the majority of his patients use and like the portal, though for some who have trouble being succinct he sometimes wishes the email function had a word limit. “You don’t want Tolstoy as a patient on the portal,” he says, smiling.
IT Could Do More
As much as he likes what the EMR allows him to do, Bain is even more focused on what he hopes it will do some day.
“We still don’t have a good enough way of collating data,” says Bain. “Let’s say a 50-year-old man comes in as a new patient, and wants a physical. I should be able to take his history, perform his physical, and enter the data in such a way that in the future, based on his age, gender, medical conditions, average life expectancy, medications, family history and past medical history, the system will tell me what the evidence-based guidelines call for going forward. What lab tests does he need, and when? What surveillance x-rays? What screening tests are worthwhile? Which ones are not? Where should we focus our efforts to have the most significant impact on his health?”
“We’ve got all these pieces of data, but they are in different places,” says Bain. “I’d like to click on a care plan and have it tell me that this guy needs a colonoscopy every ten years, and a tetanus shot, and a lipid profile every year because he’s on Simvastatin, and here is our goal for his LDL.”
Bain also wants the EMR to use more internal logic. “If I dictate that the patient smokes three packs a day, why can’t the EMR populate the problem list with ‘Current Smoker’? Why do I have to add that myself?”
He also misses the narrative nature of notes that, in the past, painted pictures of patients’ lives, and hopes EMRs will evolve in this direction. “One of the downsides of having an EMR is that too often office notes are primarily lists and templates, not the narratives of old. The EMR, in its current state, often takes the romance out of the language of medicine.”
Spreading Good Ideas
Bain has some more ideas on his IT wish list. “I wish patients could get a thumb drive from their health system that they could keep on their key ring, that would contain important encrypted health information that could be downloaded wherever they get care, particularly if they need emergency care when they are out of town,” he says.
“And wouldn’t it be great if we could leverage smartphone technology better for monitoring chronic conditions,” he says. “For example, I think what we’re going to ultimately have is a ‘smart’ strip that patients with high blood pressure can wear on their arm for days at a time that sends readings to their smartphones. The phones can collate the data and send any readings that are out of range to the doctor’s or nurse’s computer. We could leverage this sort of technology to monitor heart rate, blood sugar, weight, mood and even stress levels.”
Bain applauds the creation of CMS’s Center for Innovation, but says he also wishes there were a Center for Spread and Sustainability. “I think there are so many great ideas out there, but we’re just not able to spread them to the average practice. If something is working great in Anchorage, Alaska, why can’t I hear about this and incorporate it into my practice in Madison? What really energizes me is if we spend a little bit of time on good ideas, and a lot of time spreading them, we can make a huge impact on the future of healthcare in America.”