Looming Technological Imperatives and the Physician-Patient Relationship

The past decade has seen an explosion of new drugs, procedures, and technology. This upward trajectory of health care breakthroughs shows no sign of slowing; such innovations as molecular imaging and pharmacogenetics are within years of going prime time.

While these innovations are propelling the practice of medicine, neurologists must remain dedicated to the fundamental physician-patient relationship and adopt new technologies and procedures that nurture this bond. Possibly the most important technology that physicians need to get on board with is that of electronic health records (EHRs). Indeed, establishment of EHRs has become a government initiative. The urgency was driven home by Mark R. Anderson, a consultant with the AC Group, Inc. of Montgomery, Texas, who stated in a presentation at last year's annual meeting of the American Academy of Neurology in San Diego that "by 2009, if you don't install an EHR system, you might be out of business."¹

The adoption of an EHR system will invariably affect patient care workflow. Neurologists who are currently making notations on patients' charts while in the examination room will now require some form of data entry during the patient interaction. Because data entry in the examination room might seem intrusive not only to the physician but also to the patient, the American Academy of Family Physicians has developed etiquette guidelines²:

• The physician should face the patient and make eye contact while speaking to him or her rather than appearing overly engrossed in the content on the monitor.
• The monitor should be mobile and kept between the physician and patient to maintain the correct line of sight.
• When the patient is speaking about a concern, typing or data entry should stop to encourage a more personal interaction.
• Patients should be invited to look at the computer screen and be encouraged to participate in the documentation process.
• If templates are used, be mindful about mechanically reading a list of questions, which would stifle open dialogue.

Besides challenging patient-centered care, EHR systems challenge finances. Unlike most technologies, the cost of an EHR system has not depreciated over the years. This is because of limited competition and few early adopters. Neurologists concerned about financing an EHR system should consider leveraging existing and more cost-sensitive documenting programs. Microsoft Word or OneNote have several features that facilitate entering clinical notes in an electronic format.

These programs provide robust form and template creation features that allow text to be interspersed with variable fields. The fields allow the physician to select drop-down choices. For example, to enter the chief complaint for a patient with headaches, one sentence might read: "Features associated with the headache include _________." A drop-down menu might include: "photophobia, phonophobia, nausea, vomiting." An even more sophisticated use of Microsoft Word would use macros to present additional options depending on responses to the initial questions.

Another option for smaller group practices that want to offset the costs of implementing an EHR system is to join a group EHR network. Group practices in the same building can create an open network for the EHR or affiliate with a local hospital or academic center. However, until an industry standard is established, the barriers to entry will remain a challenge for group practices. Medicine is a business, and with EHR systems, the risks are still outweighing the benefits.

Health care technology companies can increase the benefit of an EHR system by adding more functionality and clinical value. Soon to be gone are the days when the medical record simply served to document clinical encounters. Now the record must provide clinical guidelines, clinical decision support, outcome evaluation, quality assurance, prescription writing, and drug interaction capabilities, among other functions. As a result, partnerships between EHR vendors and leading mobile reference companies, such as Epocrates, are being created to fulfill the complex needs of physicians.

PDAs: CRUCIAL DRUG REFERENCING TOOLS
Drug reference tools are another key clinical application to assist physicians in preventing common medical errors. These tools are easily accessible on mobile devices, such as personal digital assistants (PDAs) and Smartphones. A recent meta-analysis of physicians' use of PDAs showed that 45% to 85% of physicians use these devices.³ Usage rates varied by age and professional status; for example, students and residents had greater usage rates than practicing physicians. This rapid adoption is directly proportional to how mobile physicians are while traveling from hospital to clinic to home. Carrying a PDA in one's pocket makes for quick referencing of drug information where, otherwise, a physician might have to tote around multiple textbooks.

Such technology has been cited by the Institute of Medicine (IOM) as important in reducing medical errors.⁴ According to the IOM's report, Preventing Medication Errors, the number of adverse drug events (ADEs) is nothing less than staggering. The report cites one study in which 380,000 ADEs were documented per year in the hospital setting, while another study quoted 450,000.⁴ The IOM, however, suspects that these numbers are underestimates. Each ADE adds about $8750 to the cost of that hospital stay, according to the IOM report, putting medical costs attributable to medication errors at $3.5 billion annually.

Drug reference tools are the most commonly used application for physicians using a PDA. Physicians can look up drug indications and review the recommended dosing and potential ADE information. In addition, and perhaps most important, physicians can check for drug-drug interactions by entering the patient's list of medications. The program checks for interactions and provides a list of cautions for the physician to observe. This is especially useful for neurologists because their patients are often elderly and taking multiple medications for numerous health issues. More advanced drug reference systems also include information on over-the-counter supplements and can identify interactions with prescribed medications.

The top clinical application, according to the American Academy of Family Physicians, is Epocrates.⁵ A recent study in The Annals of Pharmacotherapy granted Epocrates a perfect score in its ability to detect clinically significant drug-drug interactions, making it the most reliable drug reference system evaluated.⁶ In addition to being a drug reference, Epocrates offers a differential diagnosis application that is helpful when seeing patients with uncommon conditions. Another feature worth noting for neurologists is the laboratory guide that provides recommendations, interpretation guidelines, and treatment protocols. For example, some electrolyte disturbances could cause neurologic disorders, so a neurologist may run a Chem 7 lab check to rule out potential causes.

PDAs also can be used as a communication tool to discuss treatments or laboratory results with patients. They provide the physician with tangible information to share with the patient and also show the patient that the physician is keeping current with information and trends on diagnosis and treatment. Indeed, studies show that use of handheld devices by residents in a clinical encounter is viewed positively by patients.⁷

EHR and e-prescribing software are available for PDAs, but more studies are needed to determine whether PDAs are effective devices for patient data entry because of the limited screen size and small keyboard of these devices.

ROLE OF INTERNET
The first step in reducing medication errors, according to the IOM, is transformation of the traditional "provider-centric" model of care toward a therapeutic partnership.⁴ Furthermore, the IOM suggests that patients should take a more active role in their care by educating themselves and by verifying prescriptions retrieved from the pharmacy. The Internet is playing a major role in this endeavor. More than 116 million adults in the United States reported using the Internet to find health information in 2006-an increase of 75 million persons in the past 5 years.⁴ This research demonstrates that patients are seeking information above and beyond consultations with their physician. Many are becoming more engaged in their health care, presenting to physicians with information-accurate or not-and expecting to be more involved in treatment decisions.

The Web-based catalyst to the rapid change in the relationship between the patient and physician is e-mail exchange. E-mail capability satisfies several of the IOM's rules for redesigning health care. Namely, it allows for a continuous health care relationship (not the current episodic disease intervention model), it is customizable, and it gives the patient control over his information.

The inherent advantages of an e-mail communication include the following:

• Asynchrony (avoiding "phone tag").
• Provision of written instructions with automatic documentation (compared with an ephemeral phone message).
• The ability to transmit educational material either as an attachment or as a link to reliable resources.

Patient demand rather than physician initiation will most likely drive the provision of this service. Not only are patients willing to pay for the service, but some are basing their physician choice on the availability of e-mail access capability. Furthermore, insurance companies, including Aetna, Blue Cross and Blue Shield, and Cigna, are recognizing the value of e-mail and are increasingly reimbursing physicians for their use of e-mail communications.⁸ Both the AMA and the American Medical Informatics Association have published physician guidelines for e-mail communications.^9,10 (Go to: www.ama-assn.org/ama/pub/category/2386.html to review the AMA guidelines.)

Physicians interested in creating an e-mail discourse with their patients can purchase one of several commercially available and reasonably priced products that have the built-in capabilities. The most popular systems are RelayHealth and Medem. These products provide much more than an encrypted e-mail capability and are considered to be "patient portals." They enable patients to request appointments, medication refills, and laboratory results and to pose billing questions.

RelayHealth has an electronic prescribing module, so medication refills can be done with a few mouse clicks. Medem has several educational programs available to patients through its portals. In addition, both of these programs provide personal health record (PHR) capability so that patients can maintain a repository of their relevant medical information.

PHRs are being seen as an important stepping-stone for all Americans to have some form of portable but secure health record. Because physicians are faced with the high costs of EHR system implementation, patients can track their records independently in a much more economical and efficient way. Unfortunately, current patient portals do not allow for electronic exchange of data, so each PHR remains an isolated island of information.

TECHNOLOGIZING YOUR PRACTICE
When considering the adoption of an EHR system, mobile references, and use of e-mail correspondence, physicians must evaluate both the benefit for their patients and the practical application to their day-to-day operations. While EHRs can provide significant benefit to patients, they currently are a financial burden, particularly for small office practices. In the meantime, physicians can integrate mobile applications that promise to make incremental changes in the quality of health care for their patients.

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