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Medical technology should keep patient in mind
Indeed, science and technology provide opportunities to improve outcomes in ways not even imagined 100 years ago, yet we must acknowledge that technology also threatens to erect barriers between us and our patients. We can be easily tempted to confuse new care delivery tools with the actual care itself.
Threats to the physician-patient relationship
Medical history provides many examples of how our zeal to innovate can have untoward consequences to the physician-patient relationship.
In the late 1800s, for example, to convey a sense of science, purity of intent, and trust, the medical community began wearing white coats. Those white coats have been discussed as creating emotional distance between physicians and their patients.1
Even when we in the medical community are slow and reluctant to change, the external forces propelling us forward often seem unstoppable; kinetic aspirations to innovate electronic information systems and new applications seem suddenly to revolutionize care delivery when we least expect it. The rapidity of change in technology can sometimes be dizzying but can at the same time can occur so swiftly we don’t even notice it.
After René Laennec invented the stethoscope in the early 1800s, clinicians no longer needed to physically lean in and place an ear directly onto patients to hear their hearts beating. This created a distance from patients that was still lamented 50 years later, when a professor of medicine is reported to have said, “he that hath ears to hear, let him use his ears and not a stethoscope.” Still, while the stethoscope has literally distanced us from patients, it is such an important tool that we no longer think about this distancing. We have adapted over time to remain close to our patients, to sincerely listen to their thoughts and reassure them that we hear them without the need to feel our ears on their chests.
Francis Peabody, the eminent Harvard physician, wrote an essay in 1927 titled, “The Care of the Patient.” At the end of the first paragraph, he states: “The most common criticism made at present by older practitioners is that young graduates ... are too “scientific” and do not know how to take care of patients.” He goes on to say that “one of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”2
We agree with Dr. Peabody. As we embrace science and technology that can change health outcomes, our patients’ needs to feel understood and cared for will not diminish. Instead, that need will continue to be an important aspect of our struggle and joy in providing holistic, humane, competent care into the future.
Twenty-first century physicians have access to an ever-growing trove of data, yet our ability to truly know our patients seems somehow less accessible. Home health devices have begun to provide a flow of information about parameters, ranging from continuous glucose readings to home blood pressures, weights, and inspiratory flow readings. These data can provide much more accurate insight into patients than what we can glean from one point in time during an office visit. Yet we need to remember that behind the data are people with dreams and desires, not just table entries in an electronic health record.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book, Mr. Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose, or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other people for all their complexity, in their full humanness. We must consciously remind ourselves amid the rush of technology that there are real people behind those data. We must acknowledge and approach each person as a unique individual who has dreams, goals, fears, and wishes that may be different from ours but to which we can still relate.
‘From the Beating End of the Stethoscope’
John Ciardi, an American poet, said the following in a poem titled, “Lines From the Beating End of the Stethoscope”:
I speak, as I say, the patient’s point of view.
But, given time, doctors are patients, too.
And there’s our bond: beyond anatomy,
Or in it, through it, to the mystery
Medicine takes the pulse of and lets go
Forever unexplained. It’s art, we know,
Not science at the heart. Doctor be whole,
I won’t insist the patient is a soul,
But he’s a something, possibly laughable,
Or possibly sublime, but not quite graphable.
Not quite containable on a bed chart.
Where science touches man it turns to art.3
This poem is a reminder of the subtle needs of patients during their encounters with doctors, especially around many of the most important decisions and events in their lives. Patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.
Einstein warned us that the modern age would be characterized by a perfection of means and a confusion of goals.4 As clinicians, we should strive to clarify and align our goals with those of our patients, providing care that is real, compassionate, and personal, not just an optimized means to achieve standardized metrics. While technology can assist us in this pursuit, we’ll need be careful that our enchantment with innovation does not cloud our actual goal: truly caring for our patients.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
References
1. Jones VA. The white coat: Why not follow suit? JAMA. 1999;281(5):478. doi: 10.1001/jama.281.5.478-JMS0203-5-1
2. Peabody, Francis (1927). “The care of the patient.” JAMA. 88(12):877-82. doi: 10.1001/jama.1927.02680380001001.
3. Ciardi, John. Lines from the Beating End of the Stethoscope. Saturday Review, Nov. 18, 1968.
4. Albert Einstein, Out of My Later Years, 1950.
Indeed, science and technology provide opportunities to improve outcomes in ways not even imagined 100 years ago, yet we must acknowledge that technology also threatens to erect barriers between us and our patients. We can be easily tempted to confuse new care delivery tools with the actual care itself.
Threats to the physician-patient relationship
Medical history provides many examples of how our zeal to innovate can have untoward consequences to the physician-patient relationship.
In the late 1800s, for example, to convey a sense of science, purity of intent, and trust, the medical community began wearing white coats. Those white coats have been discussed as creating emotional distance between physicians and their patients.1
Even when we in the medical community are slow and reluctant to change, the external forces propelling us forward often seem unstoppable; kinetic aspirations to innovate electronic information systems and new applications seem suddenly to revolutionize care delivery when we least expect it. The rapidity of change in technology can sometimes be dizzying but can at the same time can occur so swiftly we don’t even notice it.
After René Laennec invented the stethoscope in the early 1800s, clinicians no longer needed to physically lean in and place an ear directly onto patients to hear their hearts beating. This created a distance from patients that was still lamented 50 years later, when a professor of medicine is reported to have said, “he that hath ears to hear, let him use his ears and not a stethoscope.” Still, while the stethoscope has literally distanced us from patients, it is such an important tool that we no longer think about this distancing. We have adapted over time to remain close to our patients, to sincerely listen to their thoughts and reassure them that we hear them without the need to feel our ears on their chests.
Francis Peabody, the eminent Harvard physician, wrote an essay in 1927 titled, “The Care of the Patient.” At the end of the first paragraph, he states: “The most common criticism made at present by older practitioners is that young graduates ... are too “scientific” and do not know how to take care of patients.” He goes on to say that “one of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”2
We agree with Dr. Peabody. As we embrace science and technology that can change health outcomes, our patients’ needs to feel understood and cared for will not diminish. Instead, that need will continue to be an important aspect of our struggle and joy in providing holistic, humane, competent care into the future.
Twenty-first century physicians have access to an ever-growing trove of data, yet our ability to truly know our patients seems somehow less accessible. Home health devices have begun to provide a flow of information about parameters, ranging from continuous glucose readings to home blood pressures, weights, and inspiratory flow readings. These data can provide much more accurate insight into patients than what we can glean from one point in time during an office visit. Yet we need to remember that behind the data are people with dreams and desires, not just table entries in an electronic health record.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book, Mr. Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose, or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other people for all their complexity, in their full humanness. We must consciously remind ourselves amid the rush of technology that there are real people behind those data. We must acknowledge and approach each person as a unique individual who has dreams, goals, fears, and wishes that may be different from ours but to which we can still relate.
‘From the Beating End of the Stethoscope’
John Ciardi, an American poet, said the following in a poem titled, “Lines From the Beating End of the Stethoscope”:
I speak, as I say, the patient’s point of view.
But, given time, doctors are patients, too.
And there’s our bond: beyond anatomy,
Or in it, through it, to the mystery
Medicine takes the pulse of and lets go
Forever unexplained. It’s art, we know,
Not science at the heart. Doctor be whole,
I won’t insist the patient is a soul,
But he’s a something, possibly laughable,
Or possibly sublime, but not quite graphable.
Not quite containable on a bed chart.
Where science touches man it turns to art.3
This poem is a reminder of the subtle needs of patients during their encounters with doctors, especially around many of the most important decisions and events in their lives. Patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.
Einstein warned us that the modern age would be characterized by a perfection of means and a confusion of goals.4 As clinicians, we should strive to clarify and align our goals with those of our patients, providing care that is real, compassionate, and personal, not just an optimized means to achieve standardized metrics. While technology can assist us in this pursuit, we’ll need be careful that our enchantment with innovation does not cloud our actual goal: truly caring for our patients.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
References
1. Jones VA. The white coat: Why not follow suit? JAMA. 1999;281(5):478. doi: 10.1001/jama.281.5.478-JMS0203-5-1
2. Peabody, Francis (1927). “The care of the patient.” JAMA. 88(12):877-82. doi: 10.1001/jama.1927.02680380001001.
3. Ciardi, John. Lines from the Beating End of the Stethoscope. Saturday Review, Nov. 18, 1968.
4. Albert Einstein, Out of My Later Years, 1950.
Indeed, science and technology provide opportunities to improve outcomes in ways not even imagined 100 years ago, yet we must acknowledge that technology also threatens to erect barriers between us and our patients. We can be easily tempted to confuse new care delivery tools with the actual care itself.
Threats to the physician-patient relationship
Medical history provides many examples of how our zeal to innovate can have untoward consequences to the physician-patient relationship.
In the late 1800s, for example, to convey a sense of science, purity of intent, and trust, the medical community began wearing white coats. Those white coats have been discussed as creating emotional distance between physicians and their patients.1
Even when we in the medical community are slow and reluctant to change, the external forces propelling us forward often seem unstoppable; kinetic aspirations to innovate electronic information systems and new applications seem suddenly to revolutionize care delivery when we least expect it. The rapidity of change in technology can sometimes be dizzying but can at the same time can occur so swiftly we don’t even notice it.
After René Laennec invented the stethoscope in the early 1800s, clinicians no longer needed to physically lean in and place an ear directly onto patients to hear their hearts beating. This created a distance from patients that was still lamented 50 years later, when a professor of medicine is reported to have said, “he that hath ears to hear, let him use his ears and not a stethoscope.” Still, while the stethoscope has literally distanced us from patients, it is such an important tool that we no longer think about this distancing. We have adapted over time to remain close to our patients, to sincerely listen to their thoughts and reassure them that we hear them without the need to feel our ears on their chests.
Francis Peabody, the eminent Harvard physician, wrote an essay in 1927 titled, “The Care of the Patient.” At the end of the first paragraph, he states: “The most common criticism made at present by older practitioners is that young graduates ... are too “scientific” and do not know how to take care of patients.” He goes on to say that “one of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”2
We agree with Dr. Peabody. As we embrace science and technology that can change health outcomes, our patients’ needs to feel understood and cared for will not diminish. Instead, that need will continue to be an important aspect of our struggle and joy in providing holistic, humane, competent care into the future.
Twenty-first century physicians have access to an ever-growing trove of data, yet our ability to truly know our patients seems somehow less accessible. Home health devices have begun to provide a flow of information about parameters, ranging from continuous glucose readings to home blood pressures, weights, and inspiratory flow readings. These data can provide much more accurate insight into patients than what we can glean from one point in time during an office visit. Yet we need to remember that behind the data are people with dreams and desires, not just table entries in an electronic health record.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book, Mr. Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose, or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other people for all their complexity, in their full humanness. We must consciously remind ourselves amid the rush of technology that there are real people behind those data. We must acknowledge and approach each person as a unique individual who has dreams, goals, fears, and wishes that may be different from ours but to which we can still relate.
‘From the Beating End of the Stethoscope’
John Ciardi, an American poet, said the following in a poem titled, “Lines From the Beating End of the Stethoscope”:
I speak, as I say, the patient’s point of view.
But, given time, doctors are patients, too.
And there’s our bond: beyond anatomy,
Or in it, through it, to the mystery
Medicine takes the pulse of and lets go
Forever unexplained. It’s art, we know,
Not science at the heart. Doctor be whole,
I won’t insist the patient is a soul,
But he’s a something, possibly laughable,
Or possibly sublime, but not quite graphable.
Not quite containable on a bed chart.
Where science touches man it turns to art.3
This poem is a reminder of the subtle needs of patients during their encounters with doctors, especially around many of the most important decisions and events in their lives. Patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.
Einstein warned us that the modern age would be characterized by a perfection of means and a confusion of goals.4 As clinicians, we should strive to clarify and align our goals with those of our patients, providing care that is real, compassionate, and personal, not just an optimized means to achieve standardized metrics. While technology can assist us in this pursuit, we’ll need be careful that our enchantment with innovation does not cloud our actual goal: truly caring for our patients.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
References
1. Jones VA. The white coat: Why not follow suit? JAMA. 1999;281(5):478. doi: 10.1001/jama.281.5.478-JMS0203-5-1
2. Peabody, Francis (1927). “The care of the patient.” JAMA. 88(12):877-82. doi: 10.1001/jama.1927.02680380001001.
3. Ciardi, John. Lines from the Beating End of the Stethoscope. Saturday Review, Nov. 18, 1968.
4. Albert Einstein, Out of My Later Years, 1950.
Medication adherence challenges and helpers
For most chronic diseases, up to 20%-30% of the pills that are prescribed are not taken. In the case of inhalers for asthma and COPD, patients miss over half of the prescribed doses.
There are many things that contribute to the problem of poor adherence, but people often just simply forget. Thankfully, there are tools designed to help remind patients of what they need to take and when. A survey of apps developed to help patients remember to take their medicines found more than 700 available in Apple and Android app stores.1 Most apps focus on medication alerts, reminders, and medication logs.2 A recent review showed that apps have some – yet limited – effectiveness in increasing adherence, with patient self-reported improvements of 7%-40%.3
Another perhaps more promising area of improving adherence involves high-tech advances in the way medications can be taken. Inhalers are a primary target as they are complicated devices. A patient has to breathe in at the correct time after the inhaler is actuated, and the inhaler works optimally only if the rate of inhalation is sufficient to carry the medication into the lungs.
A number of companies have developed attachments for inhalers (and even inhalers themselves) that can record when the medication is taken through a Bluetooth connection to a patient’s smartphone. These can also assess inspiratory flow. Reminders to take the medication are built into the app, and those reminders disappear if the medication is taken. Patients can receive feedback about the quality of their timing and inspiratory rate to maximize medication delivery to the lungs.4
We learned long ago that it is difficult to take medications three to four times a day, so extended-release tablets were developed to reduce the frequency to once or twice a day. A great deal of work is now being done behind the scenes to develop medications that decrease the need for patients to remember to take their medications. The best examples of this are the long-acting reversible contraception (LARC) devices, specifically IUDs and Nexplanon. Compared with traditional oral contraceptives that need to be taken daily, LARCs reduce the rate of pregnancy by five- to tenfold.
We also now have medications for osteoporosis that can be taken monthly, or even annually. When bisphosphonates were first developed for osteoporosis prevention, they needed to be taken daily. Then a weekly bisphosphonate was developed. Now there is a once-monthly oral bisphosphonate, Ibandronate, and even a once yearly IV bisphosphonate.
Exciting developments have also occurred in the management of diabetes. We may be tempted to take for granted how once-daily long-acting insulin, which releases insulin slowly over the course of a day, has revolutionized the diabetic treatment since its Food and Drug Administration approval in 2000. Yet progress did not end there. The first GLP-1 receptor agonist for diabetes was approved in 2005 and was a twice-a-day medicine. Shortly afterward, a daily GLP-1 was approved, and now there are three once-weekly GLP-1 receptor agonists.
Several pharmaceutical manufacturers are now working on a once-weekly insulin,5 as well as an implantable GLP-1 receptor agonist that will need to be replaced every 6-12 months.6 Imagine your patient coming in once a year to replace his or her potent glucose lowering medication – one that offers a low incidence of hypoglycemia, maintains glucose control all year long, and requires no adherence to a complicated medication regimen.
Similar technology is being used to develop a once-yearly anti-HIV prophylactic medication delivery system.7 This could help prevent the spread of HIV in areas of the world where it may be difficult for people to take daily medications.7
The many technological advances we have described may help us reduce our likelihood of missing a dose of a medication. We are hopeful that progress in this area will continue, and that one day medication adherence will require even less effort from patients than it does today.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
References
1. Tabi K et al. Mobile apps for medication management: Review and analysis. JMIR Mhealth Uhealth. 2019 Sep 7(9):13608.
2. Park JYE et al. Mobile phone apps targeting medication adherence: Quality assessment and content analysis of user reviews. JMIR Mhealth Uhealth. 2019 Jan 31;7(1):e11919.
3. Pérez-Jover V et al. Mobile apps for increasing treatment adherence: Systematic review. J Med Internet Res. 2019;21(6):e12505. doi: 10.2196/12505.
4. 4 Smart inhalers that could be lifesaving for people living with asthma & COPD. MyTherapy, July 11, 2019.
5. Rosenstock J et al. Once-weekly insulin for type 2 diabetes without previous insulin treatment. N Engl J Med. 2020 Sep 22. doi: 10.1056/NEJMoa2022474.
6. GLP-1 agonists: From 2 daily injections to 1 per week and beyond. DiaTribe, Jan. 10, 2018.
7. Long-acting HIV prevention tools. Hiv.gov, July 20, 2019.
For most chronic diseases, up to 20%-30% of the pills that are prescribed are not taken. In the case of inhalers for asthma and COPD, patients miss over half of the prescribed doses.
There are many things that contribute to the problem of poor adherence, but people often just simply forget. Thankfully, there are tools designed to help remind patients of what they need to take and when. A survey of apps developed to help patients remember to take their medicines found more than 700 available in Apple and Android app stores.1 Most apps focus on medication alerts, reminders, and medication logs.2 A recent review showed that apps have some – yet limited – effectiveness in increasing adherence, with patient self-reported improvements of 7%-40%.3
Another perhaps more promising area of improving adherence involves high-tech advances in the way medications can be taken. Inhalers are a primary target as they are complicated devices. A patient has to breathe in at the correct time after the inhaler is actuated, and the inhaler works optimally only if the rate of inhalation is sufficient to carry the medication into the lungs.
A number of companies have developed attachments for inhalers (and even inhalers themselves) that can record when the medication is taken through a Bluetooth connection to a patient’s smartphone. These can also assess inspiratory flow. Reminders to take the medication are built into the app, and those reminders disappear if the medication is taken. Patients can receive feedback about the quality of their timing and inspiratory rate to maximize medication delivery to the lungs.4
We learned long ago that it is difficult to take medications three to four times a day, so extended-release tablets were developed to reduce the frequency to once or twice a day. A great deal of work is now being done behind the scenes to develop medications that decrease the need for patients to remember to take their medications. The best examples of this are the long-acting reversible contraception (LARC) devices, specifically IUDs and Nexplanon. Compared with traditional oral contraceptives that need to be taken daily, LARCs reduce the rate of pregnancy by five- to tenfold.
We also now have medications for osteoporosis that can be taken monthly, or even annually. When bisphosphonates were first developed for osteoporosis prevention, they needed to be taken daily. Then a weekly bisphosphonate was developed. Now there is a once-monthly oral bisphosphonate, Ibandronate, and even a once yearly IV bisphosphonate.
Exciting developments have also occurred in the management of diabetes. We may be tempted to take for granted how once-daily long-acting insulin, which releases insulin slowly over the course of a day, has revolutionized the diabetic treatment since its Food and Drug Administration approval in 2000. Yet progress did not end there. The first GLP-1 receptor agonist for diabetes was approved in 2005 and was a twice-a-day medicine. Shortly afterward, a daily GLP-1 was approved, and now there are three once-weekly GLP-1 receptor agonists.
Several pharmaceutical manufacturers are now working on a once-weekly insulin,5 as well as an implantable GLP-1 receptor agonist that will need to be replaced every 6-12 months.6 Imagine your patient coming in once a year to replace his or her potent glucose lowering medication – one that offers a low incidence of hypoglycemia, maintains glucose control all year long, and requires no adherence to a complicated medication regimen.
Similar technology is being used to develop a once-yearly anti-HIV prophylactic medication delivery system.7 This could help prevent the spread of HIV in areas of the world where it may be difficult for people to take daily medications.7
The many technological advances we have described may help us reduce our likelihood of missing a dose of a medication. We are hopeful that progress in this area will continue, and that one day medication adherence will require even less effort from patients than it does today.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
References
1. Tabi K et al. Mobile apps for medication management: Review and analysis. JMIR Mhealth Uhealth. 2019 Sep 7(9):13608.
2. Park JYE et al. Mobile phone apps targeting medication adherence: Quality assessment and content analysis of user reviews. JMIR Mhealth Uhealth. 2019 Jan 31;7(1):e11919.
3. Pérez-Jover V et al. Mobile apps for increasing treatment adherence: Systematic review. J Med Internet Res. 2019;21(6):e12505. doi: 10.2196/12505.
4. 4 Smart inhalers that could be lifesaving for people living with asthma & COPD. MyTherapy, July 11, 2019.
5. Rosenstock J et al. Once-weekly insulin for type 2 diabetes without previous insulin treatment. N Engl J Med. 2020 Sep 22. doi: 10.1056/NEJMoa2022474.
6. GLP-1 agonists: From 2 daily injections to 1 per week and beyond. DiaTribe, Jan. 10, 2018.
7. Long-acting HIV prevention tools. Hiv.gov, July 20, 2019.
For most chronic diseases, up to 20%-30% of the pills that are prescribed are not taken. In the case of inhalers for asthma and COPD, patients miss over half of the prescribed doses.
There are many things that contribute to the problem of poor adherence, but people often just simply forget. Thankfully, there are tools designed to help remind patients of what they need to take and when. A survey of apps developed to help patients remember to take their medicines found more than 700 available in Apple and Android app stores.1 Most apps focus on medication alerts, reminders, and medication logs.2 A recent review showed that apps have some – yet limited – effectiveness in increasing adherence, with patient self-reported improvements of 7%-40%.3
Another perhaps more promising area of improving adherence involves high-tech advances in the way medications can be taken. Inhalers are a primary target as they are complicated devices. A patient has to breathe in at the correct time after the inhaler is actuated, and the inhaler works optimally only if the rate of inhalation is sufficient to carry the medication into the lungs.
A number of companies have developed attachments for inhalers (and even inhalers themselves) that can record when the medication is taken through a Bluetooth connection to a patient’s smartphone. These can also assess inspiratory flow. Reminders to take the medication are built into the app, and those reminders disappear if the medication is taken. Patients can receive feedback about the quality of their timing and inspiratory rate to maximize medication delivery to the lungs.4
We learned long ago that it is difficult to take medications three to four times a day, so extended-release tablets were developed to reduce the frequency to once or twice a day. A great deal of work is now being done behind the scenes to develop medications that decrease the need for patients to remember to take their medications. The best examples of this are the long-acting reversible contraception (LARC) devices, specifically IUDs and Nexplanon. Compared with traditional oral contraceptives that need to be taken daily, LARCs reduce the rate of pregnancy by five- to tenfold.
We also now have medications for osteoporosis that can be taken monthly, or even annually. When bisphosphonates were first developed for osteoporosis prevention, they needed to be taken daily. Then a weekly bisphosphonate was developed. Now there is a once-monthly oral bisphosphonate, Ibandronate, and even a once yearly IV bisphosphonate.
Exciting developments have also occurred in the management of diabetes. We may be tempted to take for granted how once-daily long-acting insulin, which releases insulin slowly over the course of a day, has revolutionized the diabetic treatment since its Food and Drug Administration approval in 2000. Yet progress did not end there. The first GLP-1 receptor agonist for diabetes was approved in 2005 and was a twice-a-day medicine. Shortly afterward, a daily GLP-1 was approved, and now there are three once-weekly GLP-1 receptor agonists.
Several pharmaceutical manufacturers are now working on a once-weekly insulin,5 as well as an implantable GLP-1 receptor agonist that will need to be replaced every 6-12 months.6 Imagine your patient coming in once a year to replace his or her potent glucose lowering medication – one that offers a low incidence of hypoglycemia, maintains glucose control all year long, and requires no adherence to a complicated medication regimen.
Similar technology is being used to develop a once-yearly anti-HIV prophylactic medication delivery system.7 This could help prevent the spread of HIV in areas of the world where it may be difficult for people to take daily medications.7
The many technological advances we have described may help us reduce our likelihood of missing a dose of a medication. We are hopeful that progress in this area will continue, and that one day medication adherence will require even less effort from patients than it does today.
Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Follow him on Twitter (@doctornotte). Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.
References
1. Tabi K et al. Mobile apps for medication management: Review and analysis. JMIR Mhealth Uhealth. 2019 Sep 7(9):13608.
2. Park JYE et al. Mobile phone apps targeting medication adherence: Quality assessment and content analysis of user reviews. JMIR Mhealth Uhealth. 2019 Jan 31;7(1):e11919.
3. Pérez-Jover V et al. Mobile apps for increasing treatment adherence: Systematic review. J Med Internet Res. 2019;21(6):e12505. doi: 10.2196/12505.
4. 4 Smart inhalers that could be lifesaving for people living with asthma & COPD. MyTherapy, July 11, 2019.
5. Rosenstock J et al. Once-weekly insulin for type 2 diabetes without previous insulin treatment. N Engl J Med. 2020 Sep 22. doi: 10.1056/NEJMoa2022474.
6. GLP-1 agonists: From 2 daily injections to 1 per week and beyond. DiaTribe, Jan. 10, 2018.
7. Long-acting HIV prevention tools. Hiv.gov, July 20, 2019.
Technology and the evolution of medical knowledge: What’s happening in the background
“Knowledge comes, but wisdom lingers. It may not be difficult to store up in the mind a vast quantity of facts within a comparatively short time, but the ability to form judgments requires the severe discipline of hard work and the tempering heat of experience and maturity.” – Calvin Coolidge
The information we use every day in patient care comes from one of two sources: personal experience (our own or that of another clinician) or a research study. Up until a hundred years ago, medicine was primarily a trade in which more experienced clinicians passed along their wisdom to younger clinicians, teaching them the things that they had learned during their long and difficult careers. Knowledge accrued slowly, influenced by the biased observations of each practicing doctor. People tended to remember their successes or unusual outcomes more than their failures or ordinary outcomes. Eventually, doctors realized that their knowledge base would be more accurate and accumulate more efficiently if they looked at the outcomes of many patients given the same treatment. Thus, the observational trial emerged.
As promising and important as the dawn of observational research was, it quickly became apparent that these trials had important limitations. The most notable limitations were the potential for bias and confounding variables to influence the results. Bias occurs when the opinion of the researcher influences how the result is interpreted. Confounders occur when an outcome is generated by some unexpected aspect of the patient, environment, or medication, rather than the thing that is being studied. An example of this might be a study that finds a higher mortality rate in a city by the sea than a city located inland. From these results, one might initially conclude that the sea is unhealthy. After realizing more retired people lived in the city by the sea; however, an individual would probably change his or her mind. In this example, the older age of this city’s population would be a confounding variable that drove the increased mortality in the city by the sea.
To solve the inherent problems with observational trials, the randomized, controlled trial was developed. Our reliance on information from RCTs runs so deep that it is hard to believe that the first modern clinical trial was not reported until 1948, in a paper on streptomycin in the treatment of pulmonary tuberculosis. It followed that faith in the randomized, controlled trial reached almost religious proportions, and the belief that information that does not come from an RCT should not be relied on was held by many, until recently. Why have things changed and what does this have to do with technology?
The first is an increasing recognition that, for all of their advantages, randomized trials have one nagging but critical limitation – generalizability. Randomized trials have strict inclusion and exclusion criteria. We do not have such inclusion and exclusion criteria when we take care of patients in our offices. For example, a recent trial published in the New England Journal of Medicine (2018 Dec 4. doi: 10.1056/NEJMoa1814468.), entitled “Apixaban to prevent venous thromboembolism in patients with cancer,” concluded that apixaban therapy resulted in a lower rate of venous thromboembolism than did placebo in patients starting chemotherapy for cancer. This was a large trial with more than 500 patients enrolled, and it reached an important conclusion with significant clinical implications. When you look at the details of the article, more than 1,800 patients were assessed to find the 500 patients who were eventually included in the trial. This is fairly typical of clinical trials and raises an important point: We need to be careful about how well the results of these clinical trials can be generalized to apply to the patient in front of us. This leads us to the second development that is something happening behind the scenes that each of us has contributed to.
Real-world research
As we see each patient and type information into the EHR, we add to an enormous database of medical information. That database is increasingly being used to advance our knowledge of how medicines actually work in the real world with real patients, and has already started providing answers that supplement, clarify, and even change our perspectives. The information will provide observations derived from real populations that have not been selected or influenced by the way in which a study is conducted. This new field of research is called “real-world research.”
An example of the difference between randomized controlled trial results and real-world research was published in Diabetes Care. This article examined the effectiveness of dipeptidyl peptidase 4 (DPP-4) inhibitors vs. glucagonlike peptide–1 receptor agonists (GLP-1 RAs) in the treatment of patients with diabetes. The goal of the study was to assess the difference in change in hemoglobin A1c between real-world evidence and randomized-trial evidence after initiation of a GLP-1 RA or a DPP-4 inhibitor. In RCTs, GLP-1 RAs decreased HbA1c by about 1.3% while DPP-4 inhibitors decreased HbA1c by about 0.68% (i.e., DPP-4 inhibitors were about half as effective). However, when the effects of these two diabetes drugs were examined using clinical databases in the real world, the two classes of medications had almost the same effect, each decreasing HbA1c by about 0.5%. This difference between RCT and real-world evidence might have been caused by the differential adherence to the two classes of medications, one being an injectable with significant GI side effects, and the other being a pill with few side effects.
The important take-home point is that we are now all contributing to a massive database that can be queried to give quicker, more accurate, more relevant information. Along with personal experience and randomized trials, this third source of clinical information, when used with wisdom, will provide us with the information we need to take ever better care of patients.
References
Carls GS et al. Understanding the gap between efficacy in randomized controlled trials and effectiveness in real-world use of GLP-1 RA and DPP-4 therapies in patients with type 2 diabetes. Diabetes Care. 2017;40:1469-78.
Blonde L et al. Interpretation and impact of real-world clinical data for the practicing clinician. Adv Ther. 2018 Nov;35:1763-74.
“Knowledge comes, but wisdom lingers. It may not be difficult to store up in the mind a vast quantity of facts within a comparatively short time, but the ability to form judgments requires the severe discipline of hard work and the tempering heat of experience and maturity.” – Calvin Coolidge
The information we use every day in patient care comes from one of two sources: personal experience (our own or that of another clinician) or a research study. Up until a hundred years ago, medicine was primarily a trade in which more experienced clinicians passed along their wisdom to younger clinicians, teaching them the things that they had learned during their long and difficult careers. Knowledge accrued slowly, influenced by the biased observations of each practicing doctor. People tended to remember their successes or unusual outcomes more than their failures or ordinary outcomes. Eventually, doctors realized that their knowledge base would be more accurate and accumulate more efficiently if they looked at the outcomes of many patients given the same treatment. Thus, the observational trial emerged.
As promising and important as the dawn of observational research was, it quickly became apparent that these trials had important limitations. The most notable limitations were the potential for bias and confounding variables to influence the results. Bias occurs when the opinion of the researcher influences how the result is interpreted. Confounders occur when an outcome is generated by some unexpected aspect of the patient, environment, or medication, rather than the thing that is being studied. An example of this might be a study that finds a higher mortality rate in a city by the sea than a city located inland. From these results, one might initially conclude that the sea is unhealthy. After realizing more retired people lived in the city by the sea; however, an individual would probably change his or her mind. In this example, the older age of this city’s population would be a confounding variable that drove the increased mortality in the city by the sea.
To solve the inherent problems with observational trials, the randomized, controlled trial was developed. Our reliance on information from RCTs runs so deep that it is hard to believe that the first modern clinical trial was not reported until 1948, in a paper on streptomycin in the treatment of pulmonary tuberculosis. It followed that faith in the randomized, controlled trial reached almost religious proportions, and the belief that information that does not come from an RCT should not be relied on was held by many, until recently. Why have things changed and what does this have to do with technology?
The first is an increasing recognition that, for all of their advantages, randomized trials have one nagging but critical limitation – generalizability. Randomized trials have strict inclusion and exclusion criteria. We do not have such inclusion and exclusion criteria when we take care of patients in our offices. For example, a recent trial published in the New England Journal of Medicine (2018 Dec 4. doi: 10.1056/NEJMoa1814468.), entitled “Apixaban to prevent venous thromboembolism in patients with cancer,” concluded that apixaban therapy resulted in a lower rate of venous thromboembolism than did placebo in patients starting chemotherapy for cancer. This was a large trial with more than 500 patients enrolled, and it reached an important conclusion with significant clinical implications. When you look at the details of the article, more than 1,800 patients were assessed to find the 500 patients who were eventually included in the trial. This is fairly typical of clinical trials and raises an important point: We need to be careful about how well the results of these clinical trials can be generalized to apply to the patient in front of us. This leads us to the second development that is something happening behind the scenes that each of us has contributed to.
Real-world research
As we see each patient and type information into the EHR, we add to an enormous database of medical information. That database is increasingly being used to advance our knowledge of how medicines actually work in the real world with real patients, and has already started providing answers that supplement, clarify, and even change our perspectives. The information will provide observations derived from real populations that have not been selected or influenced by the way in which a study is conducted. This new field of research is called “real-world research.”
An example of the difference between randomized controlled trial results and real-world research was published in Diabetes Care. This article examined the effectiveness of dipeptidyl peptidase 4 (DPP-4) inhibitors vs. glucagonlike peptide–1 receptor agonists (GLP-1 RAs) in the treatment of patients with diabetes. The goal of the study was to assess the difference in change in hemoglobin A1c between real-world evidence and randomized-trial evidence after initiation of a GLP-1 RA or a DPP-4 inhibitor. In RCTs, GLP-1 RAs decreased HbA1c by about 1.3% while DPP-4 inhibitors decreased HbA1c by about 0.68% (i.e., DPP-4 inhibitors were about half as effective). However, when the effects of these two diabetes drugs were examined using clinical databases in the real world, the two classes of medications had almost the same effect, each decreasing HbA1c by about 0.5%. This difference between RCT and real-world evidence might have been caused by the differential adherence to the two classes of medications, one being an injectable with significant GI side effects, and the other being a pill with few side effects.
The important take-home point is that we are now all contributing to a massive database that can be queried to give quicker, more accurate, more relevant information. Along with personal experience and randomized trials, this third source of clinical information, when used with wisdom, will provide us with the information we need to take ever better care of patients.
References
Carls GS et al. Understanding the gap between efficacy in randomized controlled trials and effectiveness in real-world use of GLP-1 RA and DPP-4 therapies in patients with type 2 diabetes. Diabetes Care. 2017;40:1469-78.
Blonde L et al. Interpretation and impact of real-world clinical data for the practicing clinician. Adv Ther. 2018 Nov;35:1763-74.
“Knowledge comes, but wisdom lingers. It may not be difficult to store up in the mind a vast quantity of facts within a comparatively short time, but the ability to form judgments requires the severe discipline of hard work and the tempering heat of experience and maturity.” – Calvin Coolidge
The information we use every day in patient care comes from one of two sources: personal experience (our own or that of another clinician) or a research study. Up until a hundred years ago, medicine was primarily a trade in which more experienced clinicians passed along their wisdom to younger clinicians, teaching them the things that they had learned during their long and difficult careers. Knowledge accrued slowly, influenced by the biased observations of each practicing doctor. People tended to remember their successes or unusual outcomes more than their failures or ordinary outcomes. Eventually, doctors realized that their knowledge base would be more accurate and accumulate more efficiently if they looked at the outcomes of many patients given the same treatment. Thus, the observational trial emerged.
As promising and important as the dawn of observational research was, it quickly became apparent that these trials had important limitations. The most notable limitations were the potential for bias and confounding variables to influence the results. Bias occurs when the opinion of the researcher influences how the result is interpreted. Confounders occur when an outcome is generated by some unexpected aspect of the patient, environment, or medication, rather than the thing that is being studied. An example of this might be a study that finds a higher mortality rate in a city by the sea than a city located inland. From these results, one might initially conclude that the sea is unhealthy. After realizing more retired people lived in the city by the sea; however, an individual would probably change his or her mind. In this example, the older age of this city’s population would be a confounding variable that drove the increased mortality in the city by the sea.
To solve the inherent problems with observational trials, the randomized, controlled trial was developed. Our reliance on information from RCTs runs so deep that it is hard to believe that the first modern clinical trial was not reported until 1948, in a paper on streptomycin in the treatment of pulmonary tuberculosis. It followed that faith in the randomized, controlled trial reached almost religious proportions, and the belief that information that does not come from an RCT should not be relied on was held by many, until recently. Why have things changed and what does this have to do with technology?
The first is an increasing recognition that, for all of their advantages, randomized trials have one nagging but critical limitation – generalizability. Randomized trials have strict inclusion and exclusion criteria. We do not have such inclusion and exclusion criteria when we take care of patients in our offices. For example, a recent trial published in the New England Journal of Medicine (2018 Dec 4. doi: 10.1056/NEJMoa1814468.), entitled “Apixaban to prevent venous thromboembolism in patients with cancer,” concluded that apixaban therapy resulted in a lower rate of venous thromboembolism than did placebo in patients starting chemotherapy for cancer. This was a large trial with more than 500 patients enrolled, and it reached an important conclusion with significant clinical implications. When you look at the details of the article, more than 1,800 patients were assessed to find the 500 patients who were eventually included in the trial. This is fairly typical of clinical trials and raises an important point: We need to be careful about how well the results of these clinical trials can be generalized to apply to the patient in front of us. This leads us to the second development that is something happening behind the scenes that each of us has contributed to.
Real-world research
As we see each patient and type information into the EHR, we add to an enormous database of medical information. That database is increasingly being used to advance our knowledge of how medicines actually work in the real world with real patients, and has already started providing answers that supplement, clarify, and even change our perspectives. The information will provide observations derived from real populations that have not been selected or influenced by the way in which a study is conducted. This new field of research is called “real-world research.”
An example of the difference between randomized controlled trial results and real-world research was published in Diabetes Care. This article examined the effectiveness of dipeptidyl peptidase 4 (DPP-4) inhibitors vs. glucagonlike peptide–1 receptor agonists (GLP-1 RAs) in the treatment of patients with diabetes. The goal of the study was to assess the difference in change in hemoglobin A1c between real-world evidence and randomized-trial evidence after initiation of a GLP-1 RA or a DPP-4 inhibitor. In RCTs, GLP-1 RAs decreased HbA1c by about 1.3% while DPP-4 inhibitors decreased HbA1c by about 0.68% (i.e., DPP-4 inhibitors were about half as effective). However, when the effects of these two diabetes drugs were examined using clinical databases in the real world, the two classes of medications had almost the same effect, each decreasing HbA1c by about 0.5%. This difference between RCT and real-world evidence might have been caused by the differential adherence to the two classes of medications, one being an injectable with significant GI side effects, and the other being a pill with few side effects.
The important take-home point is that we are now all contributing to a massive database that can be queried to give quicker, more accurate, more relevant information. Along with personal experience and randomized trials, this third source of clinical information, when used with wisdom, will provide us with the information we need to take ever better care of patients.
References
Carls GS et al. Understanding the gap between efficacy in randomized controlled trials and effectiveness in real-world use of GLP-1 RA and DPP-4 therapies in patients with type 2 diabetes. Diabetes Care. 2017;40:1469-78.
Blonde L et al. Interpretation and impact of real-world clinical data for the practicing clinician. Adv Ther. 2018 Nov;35:1763-74.
Who is in charge here?
My first patient of the afternoon was a simple hypertension follow-up, or so I thought as I was walking into the room. She was a healthy 50-year-old woman with no medical problems other than her blood pressure, which was measured at 130/76 in the office. Her heart and lungs were normal, she had no chest pain or shortness of breath, and she was taking her medications without any problem. All simple enough. I complimented her on how she was doing, told her to continue her medications, and return in 6 months.
She put up her hand and said, “Wait a minute.”
Then she pulled out her smartphone. She tapped open an app, and handed it to me so I could look at a graph of her home blood pressures. The graph had all of her readings from the last 4 months, taken 2-3 times a day. It had automatically labeled each blood pressure in green, yellow, or red to indicate whether they were normal, higher than normal, or elevated, respectively.
Of course, the app creators had determined that a ‘green’ (normal) systolic pressure was less than 120 mm Hg. Values above that were yellow (higher than normal), until a systolic pressure of 130, at which point they became red (elevated). This is consistent with the most recent American Heart Association guidelines, but these guidelines have been the subject of a lot of controversy. There are many, including myself, who believe that the correct systolic pressure to define hypertension should be 140 for many patients, rather than 130. The app disagrees, and patients using the app see the app’s definition of hypertension every time they enter a blood pressure. In the case of my patient, since normal was indicated only by a systolic of less than 120 (which is a relatively rare event), I had to explain the difference between normal blood pressure and her blood pressure goal, and why the two were not the same.
Later that afternoon I was seeing a 60-year-old male who had electrical cardioversion of his atrial fibrillation 2 weeks prior to the visit. He had been sent home, as is usually the case, on an antiarrhythmic and an oral anticoagulant. He was feeling fine and had not noticed any palpitations, chest discomfort, or shortness of breath. I listened to his heart and lungs, which sounded normal, and I told him it sounded like he was doing well. Then he said, “I have an Apple watch.” I had a feeling I knew what was coming next.
He handed me his iPhone and asked me if I could review his rhythm strips. For those unacquainted with the new Apple watch, all he had to do to obtain those strips was open an EKG app and touch the crown of his watch with a finger from his other hand. This essentially made an electrical connection from his left to right arm, allowing the watch to generate a one-lead EKG tracing. The device then provides a computer-generated rhythm strip and sends that image and an interpretation of it to an iPhone, which is connected to the watch via Bluetooth. These results can then be shared or printed out as a pdf document.
The patient wanted to know if the smartphone’s interpretation of those rhythm strips was correct, and if he was really having frequent asymptomatic recurrence of his atrial fibrillation. Unsurprising to me or anyone who has used one of these (or other) phone-based EKG devices, the watch-generated rhythm strips looked clean and clear and the interpretation was spot on. It correctly identified his frequent asymptomatic episodes of atrial fibrillation. This was important information, which markedly affected his medical care.
These two very different examples are early indications that the way that we will be collecting information will rapidly and radically change over the next few years. It has always been clear that making long-term decisions about the treatment of hypertension based on a single reading in the office setting is not optimal. It has been equally clear that a single office EKG provides a limited snapshot into the frequency of intermittent atrial fibrillation. Deciding how to treat patients has never been easy and many decisions are plagued with ambiguity. Having limited information is a blessing and a curse; it’s quick and easy to review a small amount of data, but there is a nagging recognition that those data are only a distant representation of a patient’s real health outside of the office.
As we move forward we will increasingly have the ability to see a patient’s physiologic parameters where and when those values are most important: during the countless hours when they are not in our offices. The new American Heart Association hypertension guideline, issued in late 2017, has placed increased emphasis on ambulatory blood pressure monitoring. Determining how to use all this new information will be a challenge. It will take time to become comfortable with interpreting and making sense of an incredible number of data points. For example, if a patient checks his blood pressure twice a day for 3 months, his efforts will generate 180 separate blood pressure readings! You can bet there is going to be a good deal of inconsistency in those readings, making interpretation challenging. There will also probably be a few high readings, such as the occasional 190/110, which are likely to cause concern and anxiety in patients. There is little question that the availability of such detailed information holds the potential to allow us to make better decisions. The challenge will be in deciding how to use it to actually improve – not just complicate – patient care.
What are your thoughts on this? Feel free to email us at [email protected].
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on twitter (@doctornotte).
My first patient of the afternoon was a simple hypertension follow-up, or so I thought as I was walking into the room. She was a healthy 50-year-old woman with no medical problems other than her blood pressure, which was measured at 130/76 in the office. Her heart and lungs were normal, she had no chest pain or shortness of breath, and she was taking her medications without any problem. All simple enough. I complimented her on how she was doing, told her to continue her medications, and return in 6 months.
She put up her hand and said, “Wait a minute.”
Then she pulled out her smartphone. She tapped open an app, and handed it to me so I could look at a graph of her home blood pressures. The graph had all of her readings from the last 4 months, taken 2-3 times a day. It had automatically labeled each blood pressure in green, yellow, or red to indicate whether they were normal, higher than normal, or elevated, respectively.
Of course, the app creators had determined that a ‘green’ (normal) systolic pressure was less than 120 mm Hg. Values above that were yellow (higher than normal), until a systolic pressure of 130, at which point they became red (elevated). This is consistent with the most recent American Heart Association guidelines, but these guidelines have been the subject of a lot of controversy. There are many, including myself, who believe that the correct systolic pressure to define hypertension should be 140 for many patients, rather than 130. The app disagrees, and patients using the app see the app’s definition of hypertension every time they enter a blood pressure. In the case of my patient, since normal was indicated only by a systolic of less than 120 (which is a relatively rare event), I had to explain the difference between normal blood pressure and her blood pressure goal, and why the two were not the same.
Later that afternoon I was seeing a 60-year-old male who had electrical cardioversion of his atrial fibrillation 2 weeks prior to the visit. He had been sent home, as is usually the case, on an antiarrhythmic and an oral anticoagulant. He was feeling fine and had not noticed any palpitations, chest discomfort, or shortness of breath. I listened to his heart and lungs, which sounded normal, and I told him it sounded like he was doing well. Then he said, “I have an Apple watch.” I had a feeling I knew what was coming next.
He handed me his iPhone and asked me if I could review his rhythm strips. For those unacquainted with the new Apple watch, all he had to do to obtain those strips was open an EKG app and touch the crown of his watch with a finger from his other hand. This essentially made an electrical connection from his left to right arm, allowing the watch to generate a one-lead EKG tracing. The device then provides a computer-generated rhythm strip and sends that image and an interpretation of it to an iPhone, which is connected to the watch via Bluetooth. These results can then be shared or printed out as a pdf document.
The patient wanted to know if the smartphone’s interpretation of those rhythm strips was correct, and if he was really having frequent asymptomatic recurrence of his atrial fibrillation. Unsurprising to me or anyone who has used one of these (or other) phone-based EKG devices, the watch-generated rhythm strips looked clean and clear and the interpretation was spot on. It correctly identified his frequent asymptomatic episodes of atrial fibrillation. This was important information, which markedly affected his medical care.
These two very different examples are early indications that the way that we will be collecting information will rapidly and radically change over the next few years. It has always been clear that making long-term decisions about the treatment of hypertension based on a single reading in the office setting is not optimal. It has been equally clear that a single office EKG provides a limited snapshot into the frequency of intermittent atrial fibrillation. Deciding how to treat patients has never been easy and many decisions are plagued with ambiguity. Having limited information is a blessing and a curse; it’s quick and easy to review a small amount of data, but there is a nagging recognition that those data are only a distant representation of a patient’s real health outside of the office.
As we move forward we will increasingly have the ability to see a patient’s physiologic parameters where and when those values are most important: during the countless hours when they are not in our offices. The new American Heart Association hypertension guideline, issued in late 2017, has placed increased emphasis on ambulatory blood pressure monitoring. Determining how to use all this new information will be a challenge. It will take time to become comfortable with interpreting and making sense of an incredible number of data points. For example, if a patient checks his blood pressure twice a day for 3 months, his efforts will generate 180 separate blood pressure readings! You can bet there is going to be a good deal of inconsistency in those readings, making interpretation challenging. There will also probably be a few high readings, such as the occasional 190/110, which are likely to cause concern and anxiety in patients. There is little question that the availability of such detailed information holds the potential to allow us to make better decisions. The challenge will be in deciding how to use it to actually improve – not just complicate – patient care.
What are your thoughts on this? Feel free to email us at [email protected].
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on twitter (@doctornotte).
My first patient of the afternoon was a simple hypertension follow-up, or so I thought as I was walking into the room. She was a healthy 50-year-old woman with no medical problems other than her blood pressure, which was measured at 130/76 in the office. Her heart and lungs were normal, she had no chest pain or shortness of breath, and she was taking her medications without any problem. All simple enough. I complimented her on how she was doing, told her to continue her medications, and return in 6 months.
She put up her hand and said, “Wait a minute.”
Then she pulled out her smartphone. She tapped open an app, and handed it to me so I could look at a graph of her home blood pressures. The graph had all of her readings from the last 4 months, taken 2-3 times a day. It had automatically labeled each blood pressure in green, yellow, or red to indicate whether they were normal, higher than normal, or elevated, respectively.
Of course, the app creators had determined that a ‘green’ (normal) systolic pressure was less than 120 mm Hg. Values above that were yellow (higher than normal), until a systolic pressure of 130, at which point they became red (elevated). This is consistent with the most recent American Heart Association guidelines, but these guidelines have been the subject of a lot of controversy. There are many, including myself, who believe that the correct systolic pressure to define hypertension should be 140 for many patients, rather than 130. The app disagrees, and patients using the app see the app’s definition of hypertension every time they enter a blood pressure. In the case of my patient, since normal was indicated only by a systolic of less than 120 (which is a relatively rare event), I had to explain the difference between normal blood pressure and her blood pressure goal, and why the two were not the same.
Later that afternoon I was seeing a 60-year-old male who had electrical cardioversion of his atrial fibrillation 2 weeks prior to the visit. He had been sent home, as is usually the case, on an antiarrhythmic and an oral anticoagulant. He was feeling fine and had not noticed any palpitations, chest discomfort, or shortness of breath. I listened to his heart and lungs, which sounded normal, and I told him it sounded like he was doing well. Then he said, “I have an Apple watch.” I had a feeling I knew what was coming next.
He handed me his iPhone and asked me if I could review his rhythm strips. For those unacquainted with the new Apple watch, all he had to do to obtain those strips was open an EKG app and touch the crown of his watch with a finger from his other hand. This essentially made an electrical connection from his left to right arm, allowing the watch to generate a one-lead EKG tracing. The device then provides a computer-generated rhythm strip and sends that image and an interpretation of it to an iPhone, which is connected to the watch via Bluetooth. These results can then be shared or printed out as a pdf document.
The patient wanted to know if the smartphone’s interpretation of those rhythm strips was correct, and if he was really having frequent asymptomatic recurrence of his atrial fibrillation. Unsurprising to me or anyone who has used one of these (or other) phone-based EKG devices, the watch-generated rhythm strips looked clean and clear and the interpretation was spot on. It correctly identified his frequent asymptomatic episodes of atrial fibrillation. This was important information, which markedly affected his medical care.
These two very different examples are early indications that the way that we will be collecting information will rapidly and radically change over the next few years. It has always been clear that making long-term decisions about the treatment of hypertension based on a single reading in the office setting is not optimal. It has been equally clear that a single office EKG provides a limited snapshot into the frequency of intermittent atrial fibrillation. Deciding how to treat patients has never been easy and many decisions are plagued with ambiguity. Having limited information is a blessing and a curse; it’s quick and easy to review a small amount of data, but there is a nagging recognition that those data are only a distant representation of a patient’s real health outside of the office.
As we move forward we will increasingly have the ability to see a patient’s physiologic parameters where and when those values are most important: during the countless hours when they are not in our offices. The new American Heart Association hypertension guideline, issued in late 2017, has placed increased emphasis on ambulatory blood pressure monitoring. Determining how to use all this new information will be a challenge. It will take time to become comfortable with interpreting and making sense of an incredible number of data points. For example, if a patient checks his blood pressure twice a day for 3 months, his efforts will generate 180 separate blood pressure readings! You can bet there is going to be a good deal of inconsistency in those readings, making interpretation challenging. There will also probably be a few high readings, such as the occasional 190/110, which are likely to cause concern and anxiety in patients. There is little question that the availability of such detailed information holds the potential to allow us to make better decisions. The challenge will be in deciding how to use it to actually improve – not just complicate – patient care.
What are your thoughts on this? Feel free to email us at [email protected].
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on twitter (@doctornotte).
Martin Buber, deep learning, and the still soft voice beyond the screen
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).
Life is short, art long, opportunity fleeting. – Hippocrates
The new year provides an opportunity to reflect on old things: to decide what to keep and what to toss out, to contemplate the habits to which we choose to rededicate ourselves, and those we choose to let wane. Over the last few years, while some older physicians have expressed a yearning for the comfort of paper charts, most of us have come to embrace the benefits of the electronic health record. That is a good thing. The EHR offers many advantages over paper, and, like it or not, it’s here to stay.
The other day I was working with a resident, admitting a patient to a nursing home. I handed her the inch-thick stack of papers that came from the hospital, and she immediately asked what we were supposed to do with it. When I explained that it was the hospital chart, she wondered aloud how she was supposed to navigate to the different sections in order to review the information. I was stupefied but understood the reason behind her question. The way we document has changed so dramatically over just the past decade. Unfortunately, without intention, the way that we chart has affected the way we relate to patients.
In 1923, the German philosopher Martin Buber published the book for which he is best known, “I and Thou.” In that book Buber says that there are two ways we can approach relationships: “I-Thou” or “I-It.” In I-It relationships, we view the other person as an “it” to be used to accomplish a purpose or to be experienced without his or her full involvement. In an I-Thou relationship, we appreciate the other person for all their complexity, in their full humanness. We acknowledge and approach the person as a unique individual who has dreams, goals, fears, and wishes that may be different than ours but to which we can still relate.
While the importance and benefits of the electronic record are clear, we must constantly remind ourselves that the EHR is a tool of care and not the goal of care. While the people we see have health needs that must be diagnosed, treated, and recorded, and their illnesses are an important part of their being, they do not define their being. Nor should they define our relationship with them. Patients agree; when surveyed about the attributes of a good physician, they regularly respond that they want their physicians to have a sense of them as people, not just patients.
Recently, I was reminded of the challenge of keeping this simple task in the forefront of care while on hospital service. I had occasion to sit and talk with one of my patients without a computer in the room. This was unusual for me, as I typically fill out the EHR as I am seeing the patient. As I listened to the individual in his gown, lying on his hospital bed and describing the symptoms that brought him to the hospital, I was reminded of the subtle pauses and nuances that occur during focused conversations, during deep listening.
We have written in previous columns about exciting applications of technology that are in the pipeline. Artificial intelligence with “deep learning” is predicted to change the way we diagnose and treat disease. Deep learning is a term that has been used to describe a type of machine analysis where data are interpreted and analyzed in layers, allowing the computer to detect patterns. In the first layer of learning, the computer may identify the way pixels of the same color form a line or a curve. In the next layer it might detect the way that curve resembles a face. Peeling away layer after layer, the computer might eventually recognize whose face is being represented. This is the type of programing that has allowed computers to interpret mammograms and retina scans, detecting patterns that represent cancer or small retinal hemorrhages. While deep learning will be the subject of much excitement over the next few years, at the start of this new year we think it is equally important be reminded of an essential quality of the excellent physician – deep listening.
Deep listening requires a lifetime of practice. We have all experienced it, both as listeners and as those being listened to. When we are in the presence of someone who is truly interested in what we are saying – in our story and in our life – we feel reaffirmed and refreshed. Regardless of the topic of our discussion, we feel a sense of trust, for we believe that the person with whom we are speaking understands us, and, in that understanding, cares about us. We have a sense that we could trust the listener with our lives.
A lifetime of practice – that is the promise of our jobs as physicians. Every time we enter the exam room we have the opportunity to carry out the sacred skill of hearing others, while trying in some way to improve their lives. With each visit we have the opportunity to perfect our craft. Chaucer, the medieval English poet, observed, “the life so short, the craft so long to learn.” It seems he borrowed that idea from a physician, Hippocrates.
Hippocrates opened his medical text with the words, “Vita brevis, ars longa, occasio praeceps,” which means, “Life is short, the art long, opportunity fleeting.” Hippocrates recognized the challenge involved in learning all that is necessary to take care of our fellow man. This challenge has only become more difficult as the quantity of information required to practice competent medicine has increased. In addition, we now need to record data into the EHR to be used for record keeping, billing, and the further advancement of knowledge. Hippocrates’ medical text continued, “The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”
On the occasion of this New Year, it is a perfect time to reflect and rededicate ourselves to listening to our patients, to being interested in them and their stories. We just may find that in deep listening, and in the trust that comes from that singular focus, lie solutions to many of the largest problems we face in medicine today: burnout, poor adherence, and regaining the moral authority that comes with truly caring for those in need.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter (@doctornotte).
Real-world data, machine learning, and the reemergence of humanism
As we relentlessly enter information into our EHRs, we typically perceive that we are just recording information about our patients to provide continuity of care and have an accurate representation of what was done. While that is true, the information we record is now increasingly being examined for many additional purposes. A whole new area of study has emerged over the last few years known as “real-world data,” and innovators are beginning to explore how machine learning (currently employed in other areas by such companies as Amazon and Google) may be used to improve the care of patients. The information we are putting into our EHRs is being translated into discrete data and is then combined with data from labs, pharmacies, and claims databases to examine how medications actually work when used in the wide and wild world of practice.
Let’s first talk about why real-world data are important. Traditionally, the evidence we rely upon in medicine has come from randomized trials to give us an unbiased assessment about the safety and the efficacy of the medications that we use. The Achilles’ heel of randomized trials is that, by their nature, they employ a carefully defined group of patients – with specific inclusion and exclusion criteria – who may not be like the patients in our practices. Randomized trials are also conducted in sites that are different than most of our offices. The clinics where randomized trials are conducted have dedicated personnel to follow up on patients, to make sure that patients take their medications, and ensure that patients remember their follow up visits. What this means is that the results in of those studies might not reflect the results seen in the real world.
A nice example of this was reported recently in the area of diabetes management. Randomized trials have shown that the glucagonlike peptide–1 (GLP-1) class of medications have about twice the effectiveness in lowering hemoglobin A1c as do the dipeptidyl peptidase–4 (DPP-4) inhibitor class of medications, but that difference in efficacy is not seen in practice. When looked at in real-world studies, the two classes of medications have about the same glucose-lowering efficacy. Why might that be? In reality, it might be that compliance with GLP-1s is less than that of DPP-4s because of the side effects of nausea and GI intolerance. When patients miss more doses of their GLP-1, they do not achieve the HbA1c lowering seen in trials in which compliance is far better.1
This exploration of real-world outcomes is just a first step in using the information documented in our charts. The exciting next step will be machine learning, also called deep learning.2 In this process, computers look at an enormous number of data points and find relationships that would otherwise not be detected. Imagine a supercomputer analyzing every blood pressure after any medication is changed across thousands, or even millions, of patients, and linking the outcome of that medication choice with the next blood pressure.3 Then imagine the computer meshing millions of data points that include all patients’ weights, ages, sexes, family histories of cardiovascular disease, renal function, etc. and matching those parameters with the specific medication and follow-up blood pressures. While much has been discussed about using genetics to advance personalized medicine, one can imagine these machine-based algorithms discovering connections about which medications work best for individuals with specific characteristics – without the need for additional testing. When the final loop of this cascade is connected, the computer could present recommendations to the clinician about which medication is optimal for the patient and then refine these recommendations, based on outcomes, to optimize safety and efficacy.
Some have argued that there is no way a computer will be able to perform as well as an experienced clinician who utilizes a combination of data and intuition to choose the best medication for his or her patient. This argument is similar to the controversy over autonomous driving cars. Many have asked how you can be assured that the cars will never have an accident. That is, of course, the wrong question. The correct question, as articulated very nicely by one of the innovators in that field, George Holtz, is how we can make a car that is safer than the way that cars are currently being driven (which means fewer deaths than the 15,000 that occur annually with humans behind the wheel).4
Our current method of providing care often leaves patients without appropriate guideline-recommended medications, and many don’t reach their HbA1c, blood pressure, cholesterol, and asthma-control goals. The era of machine learning with machine-generated algorithms may be much closer than we think, which will allow us to spend more time talking with patients, educating them about their disease, and supporting them in their efforts to remain healthy – an attractive future for both us and our patients.
References
1. Carls GS et al. Understanding the gap between efficacy in randomized controlled trials and effectiveness in real-world use of GLP-1RA and DPP-4 therapies in patients with type 2 diabetes. Diabetes Care. 2017 Nov;40(11):1469-78.
2. Naylor CD. On the prospects for a (deep) learning health care system. JAMA. 2018 Sep 18;320(11):1099-100.
3. Wang YR et al. Outpatient hypertension treatment, treatment intensification, and control in Western Europe and the United States. Arch Intern Med. 2007 Jan 22;167(2):141-7.
4. Super Hacker George Hotz: “I can make your car drive itself for under $1,000.”
As we relentlessly enter information into our EHRs, we typically perceive that we are just recording information about our patients to provide continuity of care and have an accurate representation of what was done. While that is true, the information we record is now increasingly being examined for many additional purposes. A whole new area of study has emerged over the last few years known as “real-world data,” and innovators are beginning to explore how machine learning (currently employed in other areas by such companies as Amazon and Google) may be used to improve the care of patients. The information we are putting into our EHRs is being translated into discrete data and is then combined with data from labs, pharmacies, and claims databases to examine how medications actually work when used in the wide and wild world of practice.
Let’s first talk about why real-world data are important. Traditionally, the evidence we rely upon in medicine has come from randomized trials to give us an unbiased assessment about the safety and the efficacy of the medications that we use. The Achilles’ heel of randomized trials is that, by their nature, they employ a carefully defined group of patients – with specific inclusion and exclusion criteria – who may not be like the patients in our practices. Randomized trials are also conducted in sites that are different than most of our offices. The clinics where randomized trials are conducted have dedicated personnel to follow up on patients, to make sure that patients take their medications, and ensure that patients remember their follow up visits. What this means is that the results in of those studies might not reflect the results seen in the real world.
A nice example of this was reported recently in the area of diabetes management. Randomized trials have shown that the glucagonlike peptide–1 (GLP-1) class of medications have about twice the effectiveness in lowering hemoglobin A1c as do the dipeptidyl peptidase–4 (DPP-4) inhibitor class of medications, but that difference in efficacy is not seen in practice. When looked at in real-world studies, the two classes of medications have about the same glucose-lowering efficacy. Why might that be? In reality, it might be that compliance with GLP-1s is less than that of DPP-4s because of the side effects of nausea and GI intolerance. When patients miss more doses of their GLP-1, they do not achieve the HbA1c lowering seen in trials in which compliance is far better.1
This exploration of real-world outcomes is just a first step in using the information documented in our charts. The exciting next step will be machine learning, also called deep learning.2 In this process, computers look at an enormous number of data points and find relationships that would otherwise not be detected. Imagine a supercomputer analyzing every blood pressure after any medication is changed across thousands, or even millions, of patients, and linking the outcome of that medication choice with the next blood pressure.3 Then imagine the computer meshing millions of data points that include all patients’ weights, ages, sexes, family histories of cardiovascular disease, renal function, etc. and matching those parameters with the specific medication and follow-up blood pressures. While much has been discussed about using genetics to advance personalized medicine, one can imagine these machine-based algorithms discovering connections about which medications work best for individuals with specific characteristics – without the need for additional testing. When the final loop of this cascade is connected, the computer could present recommendations to the clinician about which medication is optimal for the patient and then refine these recommendations, based on outcomes, to optimize safety and efficacy.
Some have argued that there is no way a computer will be able to perform as well as an experienced clinician who utilizes a combination of data and intuition to choose the best medication for his or her patient. This argument is similar to the controversy over autonomous driving cars. Many have asked how you can be assured that the cars will never have an accident. That is, of course, the wrong question. The correct question, as articulated very nicely by one of the innovators in that field, George Holtz, is how we can make a car that is safer than the way that cars are currently being driven (which means fewer deaths than the 15,000 that occur annually with humans behind the wheel).4
Our current method of providing care often leaves patients without appropriate guideline-recommended medications, and many don’t reach their HbA1c, blood pressure, cholesterol, and asthma-control goals. The era of machine learning with machine-generated algorithms may be much closer than we think, which will allow us to spend more time talking with patients, educating them about their disease, and supporting them in their efforts to remain healthy – an attractive future for both us and our patients.
References
1. Carls GS et al. Understanding the gap between efficacy in randomized controlled trials and effectiveness in real-world use of GLP-1RA and DPP-4 therapies in patients with type 2 diabetes. Diabetes Care. 2017 Nov;40(11):1469-78.
2. Naylor CD. On the prospects for a (deep) learning health care system. JAMA. 2018 Sep 18;320(11):1099-100.
3. Wang YR et al. Outpatient hypertension treatment, treatment intensification, and control in Western Europe and the United States. Arch Intern Med. 2007 Jan 22;167(2):141-7.
4. Super Hacker George Hotz: “I can make your car drive itself for under $1,000.”
As we relentlessly enter information into our EHRs, we typically perceive that we are just recording information about our patients to provide continuity of care and have an accurate representation of what was done. While that is true, the information we record is now increasingly being examined for many additional purposes. A whole new area of study has emerged over the last few years known as “real-world data,” and innovators are beginning to explore how machine learning (currently employed in other areas by such companies as Amazon and Google) may be used to improve the care of patients. The information we are putting into our EHRs is being translated into discrete data and is then combined with data from labs, pharmacies, and claims databases to examine how medications actually work when used in the wide and wild world of practice.
Let’s first talk about why real-world data are important. Traditionally, the evidence we rely upon in medicine has come from randomized trials to give us an unbiased assessment about the safety and the efficacy of the medications that we use. The Achilles’ heel of randomized trials is that, by their nature, they employ a carefully defined group of patients – with specific inclusion and exclusion criteria – who may not be like the patients in our practices. Randomized trials are also conducted in sites that are different than most of our offices. The clinics where randomized trials are conducted have dedicated personnel to follow up on patients, to make sure that patients take their medications, and ensure that patients remember their follow up visits. What this means is that the results in of those studies might not reflect the results seen in the real world.
A nice example of this was reported recently in the area of diabetes management. Randomized trials have shown that the glucagonlike peptide–1 (GLP-1) class of medications have about twice the effectiveness in lowering hemoglobin A1c as do the dipeptidyl peptidase–4 (DPP-4) inhibitor class of medications, but that difference in efficacy is not seen in practice. When looked at in real-world studies, the two classes of medications have about the same glucose-lowering efficacy. Why might that be? In reality, it might be that compliance with GLP-1s is less than that of DPP-4s because of the side effects of nausea and GI intolerance. When patients miss more doses of their GLP-1, they do not achieve the HbA1c lowering seen in trials in which compliance is far better.1
This exploration of real-world outcomes is just a first step in using the information documented in our charts. The exciting next step will be machine learning, also called deep learning.2 In this process, computers look at an enormous number of data points and find relationships that would otherwise not be detected. Imagine a supercomputer analyzing every blood pressure after any medication is changed across thousands, or even millions, of patients, and linking the outcome of that medication choice with the next blood pressure.3 Then imagine the computer meshing millions of data points that include all patients’ weights, ages, sexes, family histories of cardiovascular disease, renal function, etc. and matching those parameters with the specific medication and follow-up blood pressures. While much has been discussed about using genetics to advance personalized medicine, one can imagine these machine-based algorithms discovering connections about which medications work best for individuals with specific characteristics – without the need for additional testing. When the final loop of this cascade is connected, the computer could present recommendations to the clinician about which medication is optimal for the patient and then refine these recommendations, based on outcomes, to optimize safety and efficacy.
Some have argued that there is no way a computer will be able to perform as well as an experienced clinician who utilizes a combination of data and intuition to choose the best medication for his or her patient. This argument is similar to the controversy over autonomous driving cars. Many have asked how you can be assured that the cars will never have an accident. That is, of course, the wrong question. The correct question, as articulated very nicely by one of the innovators in that field, George Holtz, is how we can make a car that is safer than the way that cars are currently being driven (which means fewer deaths than the 15,000 that occur annually with humans behind the wheel).4
Our current method of providing care often leaves patients without appropriate guideline-recommended medications, and many don’t reach their HbA1c, blood pressure, cholesterol, and asthma-control goals. The era of machine learning with machine-generated algorithms may be much closer than we think, which will allow us to spend more time talking with patients, educating them about their disease, and supporting them in their efforts to remain healthy – an attractive future for both us and our patients.
References
1. Carls GS et al. Understanding the gap between efficacy in randomized controlled trials and effectiveness in real-world use of GLP-1RA and DPP-4 therapies in patients with type 2 diabetes. Diabetes Care. 2017 Nov;40(11):1469-78.
2. Naylor CD. On the prospects for a (deep) learning health care system. JAMA. 2018 Sep 18;320(11):1099-100.
3. Wang YR et al. Outpatient hypertension treatment, treatment intensification, and control in Western Europe and the United States. Arch Intern Med. 2007 Jan 22;167(2):141-7.
4. Super Hacker George Hotz: “I can make your car drive itself for under $1,000.”
What is an old doctor to do?
I was in Miami recently to give a talk on diabetes when a physician, Pablo Michel, MD, asked me whether we could address an issue that’s important to him and many of his colleagues. His question was, Do we have any suggestions about how to help “older doctors” such as himself deal with electronic health records?
One of the problems with his question was that he didn’t really look “old”; he looked like he was about 50 years of age and in good shape. This physician had come on a Saturday morning to spend 4 hours learning about diabetes, which made it clear that he cared about his patients, his craft, and staying current with the medical literature.
I was struck by his questions, as well as his concern for both the quality of care for his patients and the issues he and his colleagues were facing. And it is not just him. Increased computerization of practices has been listed among the top five causes of physician burnout.1
A recent article in Annals of Internal Medicine showed that physicians spent only a quarter of their total time directly talking with patients and 50% of their time on EHR and other administrative tasks.2 It is likely that, among older physicians, the EHR takes proportionally more time and is an even larger cause of burnout. Given the importance of EHR, it seems time to revisit both the dilemma of, and propose some solutions for, this common problem.
One of the core issues for many older physicians is an inability to type. If you don’t type well, then entering a patient’s history or documenting the assessment and plan is unduly burdensome. Ten years ago, we might have suggested learning to type, which was an unrealistic recommendation then and, fortunately, is unnecessary now.
Now, solutions ranging from medical scribes to voice recognition have become commonplace. Voice recognition technology has advanced incredibly over the past 10 years, so much so that it is used now in our everyday life. The most well-known voice technology in everyday life might be Siri, Apple’s voice technology. It is easy now to dictate texts and to look up information. Similar voice technologies are available with the Amazon Echo and Google Assistant.
We now also have the advantage of well-developed medical voice recognition technology that can be used with most EHRs. Although some doctors say that the software is expensive, it can cost about $1,500 for the software and another $200-$300 for a good microphone, as well as the time to train on the software. But that expense needs to be weighed against the lost productivity of not using such software. A common complaint we hear from older doctors is that they are spending 1 to 2 hours a night completing charts. If voice recognition software could shave off half that time, decrease stress, and increase satisfaction, then it would pay for itself in 2 weeks.
Another issue is that, because the EHR enables so many things to be done from the EHR platform, many doctors find themselves doing all the work. It is important to work as a team and let each member of the team contribute to making the process more efficient. It turns out that this usually ends up being satisfying for everyone who contributes to patient care. It requires standing back from the process periodically and thinking about areas of inefficiency and how things can be done better.
One clear example is medication reconciliation: A nurse or clinical pharmacist can go over medicines with patients, and while the physician still needs to review the medications, it takes much less time to review medications than it does to enter each medication with the correct dose. Nurses also can help with preventive health initiatives. Performing recommended preventive health activities ranging from hepatitis C screening to colonoscopy can be greatly facilitated by the participation of nursing staff, and their participation will free up doctors so they can have more time to focus on diagnosis and treatment. Teamwork is critical.
Finally, if you don’t know something that is important to your practice – learn it! We are accustomed to going to CME conferences and spending our time learning about diseases like diabetes, asthma, and COPD. Each of these disease accounts for 5%-10% of the patients we see in our practice, and it is critically important to stay current and learn about them. We use our EHR for 100% of the patients we see; therefore, we should allocate time to learning about how to navigate the EHR and work more efficiently with it.
These issues are real, and the processes continue to change, but by standing back and acknowledging the challenges, we can thoughtfully construct an approach to maximize our ability to continue to have productive, gratifying careers while helping our patients.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter @doctornotte.
References
1. Medscape Physician Lifestyle Report 2015. Accessed April 27, 2018. https://www.medscape.com/slideshow/lifestyle-2015-overview-6006535#1.
2. Sinsky C et al. Ann Intern Med. 2016;165(11):753-60.
I was in Miami recently to give a talk on diabetes when a physician, Pablo Michel, MD, asked me whether we could address an issue that’s important to him and many of his colleagues. His question was, Do we have any suggestions about how to help “older doctors” such as himself deal with electronic health records?
One of the problems with his question was that he didn’t really look “old”; he looked like he was about 50 years of age and in good shape. This physician had come on a Saturday morning to spend 4 hours learning about diabetes, which made it clear that he cared about his patients, his craft, and staying current with the medical literature.
I was struck by his questions, as well as his concern for both the quality of care for his patients and the issues he and his colleagues were facing. And it is not just him. Increased computerization of practices has been listed among the top five causes of physician burnout.1
A recent article in Annals of Internal Medicine showed that physicians spent only a quarter of their total time directly talking with patients and 50% of their time on EHR and other administrative tasks.2 It is likely that, among older physicians, the EHR takes proportionally more time and is an even larger cause of burnout. Given the importance of EHR, it seems time to revisit both the dilemma of, and propose some solutions for, this common problem.
One of the core issues for many older physicians is an inability to type. If you don’t type well, then entering a patient’s history or documenting the assessment and plan is unduly burdensome. Ten years ago, we might have suggested learning to type, which was an unrealistic recommendation then and, fortunately, is unnecessary now.
Now, solutions ranging from medical scribes to voice recognition have become commonplace. Voice recognition technology has advanced incredibly over the past 10 years, so much so that it is used now in our everyday life. The most well-known voice technology in everyday life might be Siri, Apple’s voice technology. It is easy now to dictate texts and to look up information. Similar voice technologies are available with the Amazon Echo and Google Assistant.
We now also have the advantage of well-developed medical voice recognition technology that can be used with most EHRs. Although some doctors say that the software is expensive, it can cost about $1,500 for the software and another $200-$300 for a good microphone, as well as the time to train on the software. But that expense needs to be weighed against the lost productivity of not using such software. A common complaint we hear from older doctors is that they are spending 1 to 2 hours a night completing charts. If voice recognition software could shave off half that time, decrease stress, and increase satisfaction, then it would pay for itself in 2 weeks.
Another issue is that, because the EHR enables so many things to be done from the EHR platform, many doctors find themselves doing all the work. It is important to work as a team and let each member of the team contribute to making the process more efficient. It turns out that this usually ends up being satisfying for everyone who contributes to patient care. It requires standing back from the process periodically and thinking about areas of inefficiency and how things can be done better.
One clear example is medication reconciliation: A nurse or clinical pharmacist can go over medicines with patients, and while the physician still needs to review the medications, it takes much less time to review medications than it does to enter each medication with the correct dose. Nurses also can help with preventive health initiatives. Performing recommended preventive health activities ranging from hepatitis C screening to colonoscopy can be greatly facilitated by the participation of nursing staff, and their participation will free up doctors so they can have more time to focus on diagnosis and treatment. Teamwork is critical.
Finally, if you don’t know something that is important to your practice – learn it! We are accustomed to going to CME conferences and spending our time learning about diseases like diabetes, asthma, and COPD. Each of these disease accounts for 5%-10% of the patients we see in our practice, and it is critically important to stay current and learn about them. We use our EHR for 100% of the patients we see; therefore, we should allocate time to learning about how to navigate the EHR and work more efficiently with it.
These issues are real, and the processes continue to change, but by standing back and acknowledging the challenges, we can thoughtfully construct an approach to maximize our ability to continue to have productive, gratifying careers while helping our patients.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter @doctornotte.
References
1. Medscape Physician Lifestyle Report 2015. Accessed April 27, 2018. https://www.medscape.com/slideshow/lifestyle-2015-overview-6006535#1.
2. Sinsky C et al. Ann Intern Med. 2016;165(11):753-60.
I was in Miami recently to give a talk on diabetes when a physician, Pablo Michel, MD, asked me whether we could address an issue that’s important to him and many of his colleagues. His question was, Do we have any suggestions about how to help “older doctors” such as himself deal with electronic health records?
One of the problems with his question was that he didn’t really look “old”; he looked like he was about 50 years of age and in good shape. This physician had come on a Saturday morning to spend 4 hours learning about diabetes, which made it clear that he cared about his patients, his craft, and staying current with the medical literature.
I was struck by his questions, as well as his concern for both the quality of care for his patients and the issues he and his colleagues were facing. And it is not just him. Increased computerization of practices has been listed among the top five causes of physician burnout.1
A recent article in Annals of Internal Medicine showed that physicians spent only a quarter of their total time directly talking with patients and 50% of their time on EHR and other administrative tasks.2 It is likely that, among older physicians, the EHR takes proportionally more time and is an even larger cause of burnout. Given the importance of EHR, it seems time to revisit both the dilemma of, and propose some solutions for, this common problem.
One of the core issues for many older physicians is an inability to type. If you don’t type well, then entering a patient’s history or documenting the assessment and plan is unduly burdensome. Ten years ago, we might have suggested learning to type, which was an unrealistic recommendation then and, fortunately, is unnecessary now.
Now, solutions ranging from medical scribes to voice recognition have become commonplace. Voice recognition technology has advanced incredibly over the past 10 years, so much so that it is used now in our everyday life. The most well-known voice technology in everyday life might be Siri, Apple’s voice technology. It is easy now to dictate texts and to look up information. Similar voice technologies are available with the Amazon Echo and Google Assistant.
We now also have the advantage of well-developed medical voice recognition technology that can be used with most EHRs. Although some doctors say that the software is expensive, it can cost about $1,500 for the software and another $200-$300 for a good microphone, as well as the time to train on the software. But that expense needs to be weighed against the lost productivity of not using such software. A common complaint we hear from older doctors is that they are spending 1 to 2 hours a night completing charts. If voice recognition software could shave off half that time, decrease stress, and increase satisfaction, then it would pay for itself in 2 weeks.
Another issue is that, because the EHR enables so many things to be done from the EHR platform, many doctors find themselves doing all the work. It is important to work as a team and let each member of the team contribute to making the process more efficient. It turns out that this usually ends up being satisfying for everyone who contributes to patient care. It requires standing back from the process periodically and thinking about areas of inefficiency and how things can be done better.
One clear example is medication reconciliation: A nurse or clinical pharmacist can go over medicines with patients, and while the physician still needs to review the medications, it takes much less time to review medications than it does to enter each medication with the correct dose. Nurses also can help with preventive health initiatives. Performing recommended preventive health activities ranging from hepatitis C screening to colonoscopy can be greatly facilitated by the participation of nursing staff, and their participation will free up doctors so they can have more time to focus on diagnosis and treatment. Teamwork is critical.
Finally, if you don’t know something that is important to your practice – learn it! We are accustomed to going to CME conferences and spending our time learning about diseases like diabetes, asthma, and COPD. Each of these disease accounts for 5%-10% of the patients we see in our practice, and it is critically important to stay current and learn about them. We use our EHR for 100% of the patients we see; therefore, we should allocate time to learning about how to navigate the EHR and work more efficiently with it.
These issues are real, and the processes continue to change, but by standing back and acknowledging the challenges, we can thoughtfully construct an approach to maximize our ability to continue to have productive, gratifying careers while helping our patients.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington Jefferson Health. Follow him on twitter @doctornotte.
References
1. Medscape Physician Lifestyle Report 2015. Accessed April 27, 2018. https://www.medscape.com/slideshow/lifestyle-2015-overview-6006535#1.
2. Sinsky C et al. Ann Intern Med. 2016;165(11):753-60.
Preventive health: Getting rid of the middleman (uh-oh, that’s us!)
As physicians, we find that preventive health is, frankly, really difficult. It requires thinking about a changing list of recommendations unprompted by the symptoms for which patients present. Compounding that challenge is that, in doing preventive health well, we need to have personalized discussions with our patients and this requires they come into the office, which doesn’t always happen on a regular basis. Furthermore, when patients do come in, they usually are presenting for an acute care visit, so there is little time set aside to discuss preventive health.
For all these reasons and many others, the data suggest that we are not particularly good at performing preventive health maintenance. We are much better at figuring out diagnostic dilemmas and choosing among competing medications or procedures to most effectively address acute and chronic medical problems. Let’s examine the data to see if there is a shred of truth in what we are saying; then let’s look at a potential solution to the dilemma of preventive health that we all believe in and that we carry out less frequently than any of us would like.
First, let’s look at recent data on cancer screening reported by the CDC1:
- Mammography: 72% of women aged 50–74 years reported having had a mammogram within the past 2 years.
- Pap test: 83% of women reported being up to date with cervical cancer screening.
- Colorectal cancer screening: 62% of men and women reported colorectal cancer screening test use consistent with USPSTF recommendations.
Of note, colorectal cancer screening has improved dramatically over he last 15 years, while screening for breast and cervical cancer has largely plateaued.1
Our success with cancer screening – or lack thereof depending upon one’s perspective – looks quite good next to national vaccination rates for adults. The immunization rate for commonly recommended vaccines are as follows2:
- The Tdap vaccination rate is 20%.
- The tetanus-diphtheria vaccination rate is 62%.
- The herpes zoster vaccination rate is 28%.
- The influenza vaccination rate is 43%.
- The pneumococcal vaccination rate among high-risk persons aged 19-64 years is 20% and among adults aged greater than or equal to 65 years is 61%.
Of adults who had health insurance and at least 10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended.
In the business literature there is a great deal of disagreement about the value of the “middleman.” The term middleman describes someone who brings the product from the producer, or factory, to the consumer. On the one hand, if the factory can sell the product directly to the consumer, the consumer can save money and the factory can make more money. On the other hand, if the middleman can help the consumer make a better choice among the variety of products available, then the middleman provides value and the consumer benefits.3
Traditionally, clinicians have served the role of the middleman for preventive health activities, knowing what to recommend to patients and informing them of the correct preventive health choices that fit their needs. The problem with this concept is that preventive health recommendations are largely demographically based, are tied to population-based risk assessment, and usually require very little individual judgment.
We as physicians are good at – and I believe truly enjoy – exercising judgment. We love thinking things through and helping the person in front of us. We are not as good at remembering unprompted information in the middle of busy visits that are often made for unrelated reasons. Most of the people who have not had a colonoscopy or pneumococcal vaccine have not decided against the procedure after a detailed discussion with their physician. On the contrary, the service was never recommended, or it was recommended, but the patient did not follow up to have the procedure performed.
Let’s now imagine another approach. You’re a patient and once a year you click on an email that shows up in your inbox from your doctor with the words “Preventive Health” in the subject line. The EHR – based on your gender, age, and a query of what has been documented in your chart – has determined the preventive health activities that are recommended for you. You can choose to pursue, opt out, or get more information for each of the recommended preventive services as you read through them.
If you choose to have more information, it is provided in a structured format that allows you to drill down to the level of detail that you desire. In all probability, you will find a greater level of detail and accuracy of information about each preventive service than could possibly be provided during a routine office visit. Specifics about the risks and benefits of the procedure will also be more extensive, as it is unlikely your care providers are able to keep all of the details and risk ratios in their heads. If desired, you as a patient can take your time to read and digest the information, sleep on it, and come back to it to make an informed decision. This is not something you can do during a routine office visit.
If you choose to opt out of the procedure, just click the “declined” box. Otherwise, when you’ve made all of your decisions and indicate that you’re done, the necessary prescriptions for blood work and x-rays, as well as referrals to the appropriate specialists, will print out. An entry will also be made in the electronic record showing you’ve been provided preventive health recommendations that are appropriate for your age and sex and made your preferred choices. At any point, if you feel you’d like further discussion with your physician, you can make an appointment electronically through the interface.
The hurdles for implementing such a system are real, but they are solvable, and the development of such an approach is inevitable, enviable, and will ultimately be good for both patients and their providers. Patients will get more predictable and complete recommendations for preventive care and providers will have more time to do what we enjoy and are most skilled at – talking with patients to clarify diagnoses, decide upon treatment, and clarify questions that come up about preventive health recommendations.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. White A et al. Cancer screening test use – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 3;66(8):201-6.
2. Williams WW et al. Surveillance of vaccination coverage among adult populations – United States, 2014. MMWR Surveill Summ. 2016 Feb 5;65(1):1-36.
3. Conerly B. Don’t eliminate the middleman – He’s much too valuable. Forbes. Oct 28, 2015.
As physicians, we find that preventive health is, frankly, really difficult. It requires thinking about a changing list of recommendations unprompted by the symptoms for which patients present. Compounding that challenge is that, in doing preventive health well, we need to have personalized discussions with our patients and this requires they come into the office, which doesn’t always happen on a regular basis. Furthermore, when patients do come in, they usually are presenting for an acute care visit, so there is little time set aside to discuss preventive health.
For all these reasons and many others, the data suggest that we are not particularly good at performing preventive health maintenance. We are much better at figuring out diagnostic dilemmas and choosing among competing medications or procedures to most effectively address acute and chronic medical problems. Let’s examine the data to see if there is a shred of truth in what we are saying; then let’s look at a potential solution to the dilemma of preventive health that we all believe in and that we carry out less frequently than any of us would like.
First, let’s look at recent data on cancer screening reported by the CDC1:
- Mammography: 72% of women aged 50–74 years reported having had a mammogram within the past 2 years.
- Pap test: 83% of women reported being up to date with cervical cancer screening.
- Colorectal cancer screening: 62% of men and women reported colorectal cancer screening test use consistent with USPSTF recommendations.
Of note, colorectal cancer screening has improved dramatically over he last 15 years, while screening for breast and cervical cancer has largely plateaued.1
Our success with cancer screening – or lack thereof depending upon one’s perspective – looks quite good next to national vaccination rates for adults. The immunization rate for commonly recommended vaccines are as follows2:
- The Tdap vaccination rate is 20%.
- The tetanus-diphtheria vaccination rate is 62%.
- The herpes zoster vaccination rate is 28%.
- The influenza vaccination rate is 43%.
- The pneumococcal vaccination rate among high-risk persons aged 19-64 years is 20% and among adults aged greater than or equal to 65 years is 61%.
Of adults who had health insurance and at least 10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended.
In the business literature there is a great deal of disagreement about the value of the “middleman.” The term middleman describes someone who brings the product from the producer, or factory, to the consumer. On the one hand, if the factory can sell the product directly to the consumer, the consumer can save money and the factory can make more money. On the other hand, if the middleman can help the consumer make a better choice among the variety of products available, then the middleman provides value and the consumer benefits.3
Traditionally, clinicians have served the role of the middleman for preventive health activities, knowing what to recommend to patients and informing them of the correct preventive health choices that fit their needs. The problem with this concept is that preventive health recommendations are largely demographically based, are tied to population-based risk assessment, and usually require very little individual judgment.
We as physicians are good at – and I believe truly enjoy – exercising judgment. We love thinking things through and helping the person in front of us. We are not as good at remembering unprompted information in the middle of busy visits that are often made for unrelated reasons. Most of the people who have not had a colonoscopy or pneumococcal vaccine have not decided against the procedure after a detailed discussion with their physician. On the contrary, the service was never recommended, or it was recommended, but the patient did not follow up to have the procedure performed.
Let’s now imagine another approach. You’re a patient and once a year you click on an email that shows up in your inbox from your doctor with the words “Preventive Health” in the subject line. The EHR – based on your gender, age, and a query of what has been documented in your chart – has determined the preventive health activities that are recommended for you. You can choose to pursue, opt out, or get more information for each of the recommended preventive services as you read through them.
If you choose to have more information, it is provided in a structured format that allows you to drill down to the level of detail that you desire. In all probability, you will find a greater level of detail and accuracy of information about each preventive service than could possibly be provided during a routine office visit. Specifics about the risks and benefits of the procedure will also be more extensive, as it is unlikely your care providers are able to keep all of the details and risk ratios in their heads. If desired, you as a patient can take your time to read and digest the information, sleep on it, and come back to it to make an informed decision. This is not something you can do during a routine office visit.
If you choose to opt out of the procedure, just click the “declined” box. Otherwise, when you’ve made all of your decisions and indicate that you’re done, the necessary prescriptions for blood work and x-rays, as well as referrals to the appropriate specialists, will print out. An entry will also be made in the electronic record showing you’ve been provided preventive health recommendations that are appropriate for your age and sex and made your preferred choices. At any point, if you feel you’d like further discussion with your physician, you can make an appointment electronically through the interface.
The hurdles for implementing such a system are real, but they are solvable, and the development of such an approach is inevitable, enviable, and will ultimately be good for both patients and their providers. Patients will get more predictable and complete recommendations for preventive care and providers will have more time to do what we enjoy and are most skilled at – talking with patients to clarify diagnoses, decide upon treatment, and clarify questions that come up about preventive health recommendations.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. White A et al. Cancer screening test use – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 3;66(8):201-6.
2. Williams WW et al. Surveillance of vaccination coverage among adult populations – United States, 2014. MMWR Surveill Summ. 2016 Feb 5;65(1):1-36.
3. Conerly B. Don’t eliminate the middleman – He’s much too valuable. Forbes. Oct 28, 2015.
As physicians, we find that preventive health is, frankly, really difficult. It requires thinking about a changing list of recommendations unprompted by the symptoms for which patients present. Compounding that challenge is that, in doing preventive health well, we need to have personalized discussions with our patients and this requires they come into the office, which doesn’t always happen on a regular basis. Furthermore, when patients do come in, they usually are presenting for an acute care visit, so there is little time set aside to discuss preventive health.
For all these reasons and many others, the data suggest that we are not particularly good at performing preventive health maintenance. We are much better at figuring out diagnostic dilemmas and choosing among competing medications or procedures to most effectively address acute and chronic medical problems. Let’s examine the data to see if there is a shred of truth in what we are saying; then let’s look at a potential solution to the dilemma of preventive health that we all believe in and that we carry out less frequently than any of us would like.
First, let’s look at recent data on cancer screening reported by the CDC1:
- Mammography: 72% of women aged 50–74 years reported having had a mammogram within the past 2 years.
- Pap test: 83% of women reported being up to date with cervical cancer screening.
- Colorectal cancer screening: 62% of men and women reported colorectal cancer screening test use consistent with USPSTF recommendations.
Of note, colorectal cancer screening has improved dramatically over he last 15 years, while screening for breast and cervical cancer has largely plateaued.1
Our success with cancer screening – or lack thereof depending upon one’s perspective – looks quite good next to national vaccination rates for adults. The immunization rate for commonly recommended vaccines are as follows2:
- The Tdap vaccination rate is 20%.
- The tetanus-diphtheria vaccination rate is 62%.
- The herpes zoster vaccination rate is 28%.
- The influenza vaccination rate is 43%.
- The pneumococcal vaccination rate among high-risk persons aged 19-64 years is 20% and among adults aged greater than or equal to 65 years is 61%.
Of adults who had health insurance and at least 10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended.
In the business literature there is a great deal of disagreement about the value of the “middleman.” The term middleman describes someone who brings the product from the producer, or factory, to the consumer. On the one hand, if the factory can sell the product directly to the consumer, the consumer can save money and the factory can make more money. On the other hand, if the middleman can help the consumer make a better choice among the variety of products available, then the middleman provides value and the consumer benefits.3
Traditionally, clinicians have served the role of the middleman for preventive health activities, knowing what to recommend to patients and informing them of the correct preventive health choices that fit their needs. The problem with this concept is that preventive health recommendations are largely demographically based, are tied to population-based risk assessment, and usually require very little individual judgment.
We as physicians are good at – and I believe truly enjoy – exercising judgment. We love thinking things through and helping the person in front of us. We are not as good at remembering unprompted information in the middle of busy visits that are often made for unrelated reasons. Most of the people who have not had a colonoscopy or pneumococcal vaccine have not decided against the procedure after a detailed discussion with their physician. On the contrary, the service was never recommended, or it was recommended, but the patient did not follow up to have the procedure performed.
Let’s now imagine another approach. You’re a patient and once a year you click on an email that shows up in your inbox from your doctor with the words “Preventive Health” in the subject line. The EHR – based on your gender, age, and a query of what has been documented in your chart – has determined the preventive health activities that are recommended for you. You can choose to pursue, opt out, or get more information for each of the recommended preventive services as you read through them.
If you choose to have more information, it is provided in a structured format that allows you to drill down to the level of detail that you desire. In all probability, you will find a greater level of detail and accuracy of information about each preventive service than could possibly be provided during a routine office visit. Specifics about the risks and benefits of the procedure will also be more extensive, as it is unlikely your care providers are able to keep all of the details and risk ratios in their heads. If desired, you as a patient can take your time to read and digest the information, sleep on it, and come back to it to make an informed decision. This is not something you can do during a routine office visit.
If you choose to opt out of the procedure, just click the “declined” box. Otherwise, when you’ve made all of your decisions and indicate that you’re done, the necessary prescriptions for blood work and x-rays, as well as referrals to the appropriate specialists, will print out. An entry will also be made in the electronic record showing you’ve been provided preventive health recommendations that are appropriate for your age and sex and made your preferred choices. At any point, if you feel you’d like further discussion with your physician, you can make an appointment electronically through the interface.
The hurdles for implementing such a system are real, but they are solvable, and the development of such an approach is inevitable, enviable, and will ultimately be good for both patients and their providers. Patients will get more predictable and complete recommendations for preventive care and providers will have more time to do what we enjoy and are most skilled at – talking with patients to clarify diagnoses, decide upon treatment, and clarify questions that come up about preventive health recommendations.
Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
References
1. White A et al. Cancer screening test use – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 3;66(8):201-6.
2. Williams WW et al. Surveillance of vaccination coverage among adult populations – United States, 2014. MMWR Surveill Summ. 2016 Feb 5;65(1):1-36.
3. Conerly B. Don’t eliminate the middleman – He’s much too valuable. Forbes. Oct 28, 2015.
The Inflection Point
In the early 1600s, the French playwright Molière wrote one of the great satires of all time, “The Doctor in Spite of Himself.” In that play the main character, Sganarelle, is a woodcutter who wastes all his money on alcohol, so his wife Martine decides she will teach him a lesson. As she is plotting her revenge, Martine overhears two peasants discussing how they have been trying to find a doctor for their rich employer’s daughter, who has become suddenly mute. Martine seizes the opportunity to tell the peasants that her husband is a brilliant – though eccentric – doctor who usually hides his identity. Learning this, the peasants find Sganarelle and beg him to see their master’s daughter. Though he initially refuses, they berate him until he can take it no more, and he finally says that he is a doctor and agrees to assess the ill young woman.
Sganarelle does his best to impersonate a doctor while examining the young woman, and as he is doing so it becomes apparent even to him that she is not truly ill. She is pretending to be mute because she’s being forced to marry a wealthy man she does not love. Sganarelle discusses the diagnosis with her father, stating, “this impediment to the action of the tongue is caused by certain humors.” He goes on to say that her muteness was triggered by, “the vapors that pass from the left side, where the liver resides, to the right side, where the heart dwells.” The rich aristocrat listens intently and accepts the diagnosis, though he seems puzzled about one thing. “Isn’t the heart on the left side of the chest?” he asks. To this insightful and obvious question Sganarelle replies, “Yes, that used to be true; but we’ve changed all that, and we practice medicine now according to a whole new method.”
It is astonishing that Molière, in a farcical comedy written in the 1600s, could have anticipated the dizzying rate of change in modern medicine. While the heart and liver have not changed sides, the ways we are practicing medicine have undergone landmark shifts over the past 10 years. Just look at the new ways in which we record documentation, learn new information, send in prescriptions, manage populations in addition to individual patients, and so many other aspects of care. At times this evolution has its own satirical feel to it. For example, the notion that refusing to refill an opioid prescription for a patient that broke their opioid contract could lead to a bad review on Yelp or points off on a Press Ganey satisfaction survey does not seem reasonable, but it is real.
When we started this column about 10 years ago, we regularly received emails (and even letters written in fine penmanship and mailed in envelopes) from physicians who felt that the EHR was ruining their practice and their lives. Many of the letters talked about early retirement. Some physicians ended up retiring early. Many of these physicians were smart, able people who we believe took great care of patients. But as Leon C. Megginson, interpreting the work of Darwin, observed, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” Adaptability favors the young; the young have fewer habits to break, few preconceived ideas of how things should be, and perhaps more energy to give to new tasks.
We believe we have now reached the inflection point – a time in the history of an industry where an event (in this case the advent of the EHR) so fundamentally impacts the industry that the industry is changed from that point forward. The industry, and more importantly those who work in the industry, must adopt new approaches and attitudes in order to survive in the changed environment. Andrew Grove, the former CEO of Intel, talked about Strategic Inflection Points in a keynote address to the Academy of Management: “…what is common to [inflection points] and what is key is that they require a fundamental change in business strategy.” Grove also said, “That change can mean an opportunity to rise to new heights. But it may just as likely signal the beginning of the end.”
Up until recently, the introduction of the EHR lead to discussions about what was good and what was bad about the advent of EHRs. That time is past. We no longer receive letters from physicians expressing their concerns about the EHR, as many of those physicians have taken the change as a signal of the end of their careers, and chosen to retire. The rest have adapted to a new world. And in this new world we are certainly rising to new heights. We are forward-focused and looking at the multi-fold ways that our new technologies can accomplish their many missions – to improve the health of the population, to serve as a source of data to assess the real-world effectiveness of novel therapies, to evaluate and affect the quality of care given by practices and individual physicians, and to take excellent personalized care of individual patients. While we are physicians, not wood cutters as in Molière’s play, it remains incumbent upon us never to stop listening to our patients’ hearts, and to interpret their symptoms and signs with common sense, empathy and even humor when appropriate, all the while embracing approaches that move the health care of our patients forward to new heights.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
In the early 1600s, the French playwright Molière wrote one of the great satires of all time, “The Doctor in Spite of Himself.” In that play the main character, Sganarelle, is a woodcutter who wastes all his money on alcohol, so his wife Martine decides she will teach him a lesson. As she is plotting her revenge, Martine overhears two peasants discussing how they have been trying to find a doctor for their rich employer’s daughter, who has become suddenly mute. Martine seizes the opportunity to tell the peasants that her husband is a brilliant – though eccentric – doctor who usually hides his identity. Learning this, the peasants find Sganarelle and beg him to see their master’s daughter. Though he initially refuses, they berate him until he can take it no more, and he finally says that he is a doctor and agrees to assess the ill young woman.
Sganarelle does his best to impersonate a doctor while examining the young woman, and as he is doing so it becomes apparent even to him that she is not truly ill. She is pretending to be mute because she’s being forced to marry a wealthy man she does not love. Sganarelle discusses the diagnosis with her father, stating, “this impediment to the action of the tongue is caused by certain humors.” He goes on to say that her muteness was triggered by, “the vapors that pass from the left side, where the liver resides, to the right side, where the heart dwells.” The rich aristocrat listens intently and accepts the diagnosis, though he seems puzzled about one thing. “Isn’t the heart on the left side of the chest?” he asks. To this insightful and obvious question Sganarelle replies, “Yes, that used to be true; but we’ve changed all that, and we practice medicine now according to a whole new method.”
It is astonishing that Molière, in a farcical comedy written in the 1600s, could have anticipated the dizzying rate of change in modern medicine. While the heart and liver have not changed sides, the ways we are practicing medicine have undergone landmark shifts over the past 10 years. Just look at the new ways in which we record documentation, learn new information, send in prescriptions, manage populations in addition to individual patients, and so many other aspects of care. At times this evolution has its own satirical feel to it. For example, the notion that refusing to refill an opioid prescription for a patient that broke their opioid contract could lead to a bad review on Yelp or points off on a Press Ganey satisfaction survey does not seem reasonable, but it is real.
When we started this column about 10 years ago, we regularly received emails (and even letters written in fine penmanship and mailed in envelopes) from physicians who felt that the EHR was ruining their practice and their lives. Many of the letters talked about early retirement. Some physicians ended up retiring early. Many of these physicians were smart, able people who we believe took great care of patients. But as Leon C. Megginson, interpreting the work of Darwin, observed, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” Adaptability favors the young; the young have fewer habits to break, few preconceived ideas of how things should be, and perhaps more energy to give to new tasks.
We believe we have now reached the inflection point – a time in the history of an industry where an event (in this case the advent of the EHR) so fundamentally impacts the industry that the industry is changed from that point forward. The industry, and more importantly those who work in the industry, must adopt new approaches and attitudes in order to survive in the changed environment. Andrew Grove, the former CEO of Intel, talked about Strategic Inflection Points in a keynote address to the Academy of Management: “…what is common to [inflection points] and what is key is that they require a fundamental change in business strategy.” Grove also said, “That change can mean an opportunity to rise to new heights. But it may just as likely signal the beginning of the end.”
Up until recently, the introduction of the EHR lead to discussions about what was good and what was bad about the advent of EHRs. That time is past. We no longer receive letters from physicians expressing their concerns about the EHR, as many of those physicians have taken the change as a signal of the end of their careers, and chosen to retire. The rest have adapted to a new world. And in this new world we are certainly rising to new heights. We are forward-focused and looking at the multi-fold ways that our new technologies can accomplish their many missions – to improve the health of the population, to serve as a source of data to assess the real-world effectiveness of novel therapies, to evaluate and affect the quality of care given by practices and individual physicians, and to take excellent personalized care of individual patients. While we are physicians, not wood cutters as in Molière’s play, it remains incumbent upon us never to stop listening to our patients’ hearts, and to interpret their symptoms and signs with common sense, empathy and even humor when appropriate, all the while embracing approaches that move the health care of our patients forward to new heights.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
In the early 1600s, the French playwright Molière wrote one of the great satires of all time, “The Doctor in Spite of Himself.” In that play the main character, Sganarelle, is a woodcutter who wastes all his money on alcohol, so his wife Martine decides she will teach him a lesson. As she is plotting her revenge, Martine overhears two peasants discussing how they have been trying to find a doctor for their rich employer’s daughter, who has become suddenly mute. Martine seizes the opportunity to tell the peasants that her husband is a brilliant – though eccentric – doctor who usually hides his identity. Learning this, the peasants find Sganarelle and beg him to see their master’s daughter. Though he initially refuses, they berate him until he can take it no more, and he finally says that he is a doctor and agrees to assess the ill young woman.
Sganarelle does his best to impersonate a doctor while examining the young woman, and as he is doing so it becomes apparent even to him that she is not truly ill. She is pretending to be mute because she’s being forced to marry a wealthy man she does not love. Sganarelle discusses the diagnosis with her father, stating, “this impediment to the action of the tongue is caused by certain humors.” He goes on to say that her muteness was triggered by, “the vapors that pass from the left side, where the liver resides, to the right side, where the heart dwells.” The rich aristocrat listens intently and accepts the diagnosis, though he seems puzzled about one thing. “Isn’t the heart on the left side of the chest?” he asks. To this insightful and obvious question Sganarelle replies, “Yes, that used to be true; but we’ve changed all that, and we practice medicine now according to a whole new method.”
It is astonishing that Molière, in a farcical comedy written in the 1600s, could have anticipated the dizzying rate of change in modern medicine. While the heart and liver have not changed sides, the ways we are practicing medicine have undergone landmark shifts over the past 10 years. Just look at the new ways in which we record documentation, learn new information, send in prescriptions, manage populations in addition to individual patients, and so many other aspects of care. At times this evolution has its own satirical feel to it. For example, the notion that refusing to refill an opioid prescription for a patient that broke their opioid contract could lead to a bad review on Yelp or points off on a Press Ganey satisfaction survey does not seem reasonable, but it is real.
When we started this column about 10 years ago, we regularly received emails (and even letters written in fine penmanship and mailed in envelopes) from physicians who felt that the EHR was ruining their practice and their lives. Many of the letters talked about early retirement. Some physicians ended up retiring early. Many of these physicians were smart, able people who we believe took great care of patients. But as Leon C. Megginson, interpreting the work of Darwin, observed, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” Adaptability favors the young; the young have fewer habits to break, few preconceived ideas of how things should be, and perhaps more energy to give to new tasks.
We believe we have now reached the inflection point – a time in the history of an industry where an event (in this case the advent of the EHR) so fundamentally impacts the industry that the industry is changed from that point forward. The industry, and more importantly those who work in the industry, must adopt new approaches and attitudes in order to survive in the changed environment. Andrew Grove, the former CEO of Intel, talked about Strategic Inflection Points in a keynote address to the Academy of Management: “…what is common to [inflection points] and what is key is that they require a fundamental change in business strategy.” Grove also said, “That change can mean an opportunity to rise to new heights. But it may just as likely signal the beginning of the end.”
Up until recently, the introduction of the EHR lead to discussions about what was good and what was bad about the advent of EHRs. That time is past. We no longer receive letters from physicians expressing their concerns about the EHR, as many of those physicians have taken the change as a signal of the end of their careers, and chosen to retire. The rest have adapted to a new world. And in this new world we are certainly rising to new heights. We are forward-focused and looking at the multi-fold ways that our new technologies can accomplish their many missions – to improve the health of the population, to serve as a source of data to assess the real-world effectiveness of novel therapies, to evaluate and affect the quality of care given by practices and individual physicians, and to take excellent personalized care of individual patients. While we are physicians, not wood cutters as in Molière’s play, it remains incumbent upon us never to stop listening to our patients’ hearts, and to interpret their symptoms and signs with common sense, empathy and even humor when appropriate, all the while embracing approaches that move the health care of our patients forward to new heights.
Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
Our new year’s resolutions
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
Be at war with your vices, at peace with your neighbors, and let every new year find you a better person.
– Benjamin Franklin
Traditionally, the new year is a time for reflection, looking back to review what could have been done better, and looking forward to the opportunity to rectify those inadequacies over the coming year. We thought we would take this opportunity to look at our use of the electronic health record and think about the things we might do over the next year to make our lives easier and our charting better.
Top of our list is a renewed commitment to finish our notes by the end of each session. Too many physicians we know rush through patient hours and then are left with 10-20 notes to finish at the end of the day. Realistically, this is when we least feel like completing notes. Such work encroaches on personal and family time, likely contributes to the burnout that has been increasing among physicians, and is much less likely to accurately represent the encounter than notes completed in real time.
As we have spoken with many of our colleagues, it has become clear to us that many clinicians have learned how to be “just proficient enough” in their use of their EHR; they are not pulling out their hair every 5 minutes in frustration, but they have not taken the extra time and effort that are needed to optimize their productivity. To efficiently use an EHR requires some time spent designing templates and macros to make it easy to repetitively carry out common tasks.
A lot of physicians – particularly physicians over 40 years of age – are still typing their notes with the ol’ two-finger hunt-and-peck technique. This is incredibly time consuming, inefficient, and frustrating.
While many solutions have been proposed, including having a scribe walk around with the doctor, the simplest and easiest to implement is voice transcription. Even though medical transcription software is expensive, the return on investment is large for those who do not type well. After a short period of training on the software, notes are generally of higher quality and are finished considerably faster than when typing. The technology also has the ability to learn the names of frequently used consultants, medications, and procedures, so users don’t even have to type uncommon names or words.
Another area in which we hope to advance over the next year is working more effectively as a team to share the documentation burden. Nurses and medical assistants – within the boundaries of their licensing – can be empowered to document in predefined areas of the chart as much as possible.
For example, given the fact that the prevalence of depression is about twice as high in patients with diabetes as it is in the general population, our medical assistants now screen our diabetes patients with a PHQ-2 depression screen and record the results in the chart. This has been good for our patients, satisfying for our medical assistants, and has offloaded this task from the doctors.
We need to think of more areas where we can facilitate team care and really make everyone – physicians, nurses, front staff, and patients – more satisfied with the care that is being given.
Most EHRs have a reminder function – the ability to prompt a user to follow up on an abnormal x-ray or lab results in case a patient does not come back into the office as recommended. Our sense is that most of us are not using this function. It is worth finding out how to use it and giving it a try.
Patient portals have gained a lot of traction over the past few years. For a little while, we were really making an effort to have patients register, so that currently many (but by far not most) of our patients have signed up. We want to make better use of this fantastic resource.
We say “fantastic” because when we talk to patients (or friends or family) who use the portal, they have shared that it really makes their lives easier. They are able to see their labs, ponder the meaning of their results (perhaps of a slightly high glucose or an LDL cholesterol level), and if they have questions, they can correspond electronically with their care providers. It enhances care and allows us to spend less time on the phone, while giving patients better access to information.
New year’s resolutions are an opportunity for reflection and optimism. As we look back on the past year, we should learn from our experience and approach the year in front of us with greater enthusiasm, in the hope that through that enthusiasm we can continue to grow, be better and healthier, and simply be more like the people we want to be.
The electronic health record affects all of our interactions with patients and colleagues, and, when not used optimally, encroaches into our personal and family lives. It is a perfect place to focus during the new year to enable us to have more productive, effective, and happier times both in the office and at home.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.