Thursday, September 26, 2013

Here Is A Health IT Debate We Probably Need To Have. What Do You Think?

This appeared a few days ago.

Do Physicians Spend Too Much Time With Computers?

SEP 17, 2013 9:35am ET
A recent study of work hours of medical interns in the new era of duty hour regulations produced an interesting side finding, which is that modern medical interns spend about 40% of their time at a computer [1]. To some, this prompted concern that computers were drawing medical trainees away from patients and their care.
A finding like this certainly warrants attention. However, I wonder whether many expressing concern are asking the wrong question. The proper question is not whether this is too much time at a computer, but rather if this amount of time compromises the interns' care of their patients or of their learning experience.
Implicit among those who raise the question of too much time with computers is the assumption that computers are taking physicians away from patients. It is instructive, however, to consider historic data of how much time physicians spend in direct vs. indirect care of patients. It turns out that physicians have historically spent most of their working time in activities other than in the presence of their patients.
Time studies of hospital [2-6] and emergency [7] physicians show physicians spend about 15-38% of their time in direct patient care versus 50-67% of their time in indirect patient care, divided among reviewing results, performing documentation, and engaging in communication. Likewise, studies of outpatient physicians find that 14-39% of work takes place outside the exam room [8-9]. In addition, work related to patients when they are not even present at the hospital or office consumes 15-23% of the physician work day [9-11].
Therefore, this new study does not necessarily indicate the computers are drawing physicians away from patients.
By William Hersh, M.D., professor and chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University. Dr. Hersh blogs as the Informatics Professor.
This is quite an interesting issue.
In the past there has been concern about how the use of a computer while providing patient care might interfere with the doctor-patient communication and relationship and some have made some good suggestions about how to minimise the impact.
There is a useful very recent article here:

Doctors Need More Training on How To Use EHRs During Patient Encounters

by Ken Terry, iHealthBeat Contributing Reporter
The use of electronic health records in the exam room need not harm the doctor-patient relationship if physicians use EHRs properly, according to a recent report from the American Medical Association Board of Trustees. But observers raise some serious questions about how EHRs may be changing doctor-patient interaction and about whether physicians are trained well enough to know what they're doing.
William Ventres -- an Oregon family physician who coauthored a Family Practice Management piece on the subject -- said that many physicians are too absorbed in their computers to pay adequate attention to their patients during office visits. A major reason for this, he said, is insufficient training.
"Most people starting out with EHRs get very little training on how to use them in terms of the doctor-patient relationship," he noted. "The computer is put down in front of them and they're told to 'use it.' And there are many different ways of using it, but people don't get that education."
Lots more here:
I think any concerns with all this should be balanced by the benefits received by both clinician and patient if the clinician has access to accurate records and other relevant information (lab results and the like).
Clearly there is also benefit to be had if we ensure the patient can see what is being recorded, correct if necessary, and develop a better understanding of what is happening to them.
There is a useful blog discussing this issue here:
Overall, as long as systems provide good workflow support, I think there is considerable upside and limited downside with computer use. What do others think?


Bernard Robertson-Dunn said...

There is talk about a review of the PCEHR. I've pontificated about audit/assurance/assessment elsewhere and I've also been harping on about health outcomes.

For those asking for a review and for those doing it, I suggest they acquaint themselves with this blog

Getting Real About Health Care Value,
by David Blumenthal and Kristof Stremikis
Harvard Business Review
September 17, 2013

The key sentence is:
Michael Porter has defined value as “health outcomes achieved per dollar spent.
The reference is to a paper dated December 2010, so it's not exactly new.

IMHO, the first (and potentially only) question for the review is:
What health outcomes has the PCEHR directly achieved or can be demonstrated will achieve in the future?

Anonymous said...

Bernard you are correct and is the $1 Billion dollar question?

Hopefully we won't receive a $2 Billion dollar answer

Bernard Robertson-Dunn said...

Anon said "Hopefully we won't receive a $2 Billion dollar answer"

If the review demonstrates in a credible and justifiable manner that the PCEHR is delivering $2billion of value in health outcomes then great.

We have a pretty good idea of the cost, it's the value that's unclear.

BTW, the true cost of a system like the PCEHR, in terms of support, maintenance, upgrades etc is significant. I do hope they don't conveniently forget things like an allocation of DOHS' data centre and comms costs, OS and other licence fees, help desk, etc.

IMHO, the cost could easily reach $2billion over a three to five year period.

But let's see what they come up with, and how much they share with us.

However, as any student of Yes Minister knows, you don't call for a review without knowing the answer in advance.

So, here's a bit of speculation based upon no information whatsoever.

They've decided already what they will do with the PCEHR.

If the review maximises the costs and minimises the health outcomes - the PCEHR is dead in the water.

If they minimise and hide the costs and talk up the benefits - they will be keeping the PCEHR.

I don't know what the review will say, but the answer will be a political answer. The review will support the political answer.

Anonymous said...

“BTW, the true cost of a system like the PCEHR, in terms of support, maintenance, upgrades etc is significant. I do hope they don't conveniently forget things…”
And please don’t forget the costs incurred in hospitals and healthcare services in the changes required to implement systems and processes to post to and view the PCEHR. Without these, the PCEHR is not useful, and yet here has never been an understanding of the amount of work and effort required to populate and access the PCEHR. Many have not yet achieved this even now.

Bernard Robertson-Dunn said...

I agree with the previous poster re including costs incurred in hospitals and healthcare services.

This actually raises an interesting question re usage of the PCEHR.

Assuming that hospitals and healthcare services have their own IT systems, which healthcare professionals routinely use and which feed data to the PCEHR.

Why would a healthcare professional use the PCEHR, which only contains summary data and pointers to other systems?

Is this assumption correct? The South Australian example referred to earlier on this blog would suggest that, even if it isn't currently the case, soon will be.