Thursday, August 25, 2011

Doc why are you asking me all these questions? All that information is in the computer!

Disclaimer: This is a hypothetical case - any resemblance to anyone is purely coincidental.
Addendum 8/28/2011 Link to G+ discussion on this post 

Students learn about patient centered interviewing and focusing on patient problems and complaints.  That is the point of HPI (History of present illness).  When they come to work with a primary care provider, who has know his/her patients for a long time, some of these question can be irritating to the patient who expects the physician to remember everything about their health history.

The HPI helps when approaching a patient with a new problem. Students are often not familiar with the patient who has 5 serious chronic problems but no complaints.  They start by asking something like, "So what brings you in today?" and they get something like "Oh, this is just a follow up.  I am fine!" and then they don't know what to do next.

Part of the problem is that many medical students get only an acute exposure to chronic diseases.  They do an 8 week rotation in Internal Medicine where they almost never see the same patient again.

Recently I had a patient who came in to establish care.  She was the first patient of the day and she was 15 minutes late.  I had come in earlier than usual as I knew I had a third year student with me in clinic.  Because of these reasons, I got time to review her EHR data in some detail.  She had received all her care at our institution and this meant all her data was in one system.

The student was very bright and very comfortable with history taking but new to EHRs.  The previous day, she had faced the typical patient scenario, "Why are you asking me all these questions?  Its all there in the computer!"

After that last encounter, we had discussed how a lot of information can be gleaned from the EHR.  So we had decided to spend some time going over the strategy of using the EHR prior to seeing the patient.

We started off by looking at a Patient summary screen (a snapshot of her problem list, medications and health maintenance alerts). We saw that she had the following issues noted in the EHR by her previous physician:

1.  Hyperlipidemia
2.  Goiter
3.  Smoker
4.  Hypertension
Her medications included
1.  HCTZ 25
2.  Pravastatin 40

So in this patient we went over her chronic issues (problem list) and dug into each one to see what we could glean from the EHR.  This is how the conversation went:

1.  Lets look at the hyperlipidemia.  What would you want to know?
  • Last lipid level
  • Target LDL (how do we calculate this?) 
  • What medication, dose, is she compliant, tolerating?
  • Liver test results
  • Diet and exercise
So we click on Chart review >>; Lab results>> Select the last 2 lipid panels >> view in table form >> find that her LDL was about 150 1 year back.
We discuss ATP III >> go to the ATP calculator online >> put in her risk factors >> calculate that her LDL should be less than 130 mg/dL
We assume that whoever ordered that last lipid panel must have done something when the LDL came back above the target.  Go to Medication tab >> medication history >> sort by therapeutic class >> look for lipid lower meds >> find that she used to be on pravastatin 20 and had been increased to 40 mg after the date of the lab.  Did that work?  Lab results >> see that lipids and ALT had been ordered for 3 months after the change in dosage but not done.
So we create one agenda item: Find out if she is taking the 40 mg dose, and check lipids on that dose.

I recall reading about the new JAMA study on the dietary portfolio (oatmeal, soy and nuts) being better than just following a low saturated fat diet at lowering cholesterol.  Find it in Google Reader easily and share with student.
Create second agenda item: Discuss diet with patient and d/w her re' this study

2.  Goiter:  What questions do we have?
  • Has this been worked up? 
  • What was found?
  • What was done?
  • What is her thyroid status?
  • She is not on any meds so is she euthyroid?
So we click on the problem "Goiter" in the EHR and find that it was first noted in 2007.
Chart review >> Imaging>> USG thyroid >> has one large nodule and rest diffusely enlarged.
D/w student what she would do>> FNA >> Who does this? Endocrinology>> chart review >> Encounter tab >> sort by department >>Endocrinology >> saw them in 2008 >> had an FNA done>> Lab results tab>> Sort by test >> Surgical pathology >> Thyroid bx>> Benign. Also check last TSH >> low normal 2 years back.

Create agenda: Update problem list with this information so next physician does not have to do this again! Another agenda item: Ask also about symptoms and recheck TSH.

3.  Smoker: What would you want to know?
  • Is she still smoking?
  • If so is she interested in quitting?
Create agenda to ask these questions.

4.  Hypertension:  What would you want to know?
  • What is the BP today?
  • Is she taking her medication?  and side effect?
  • How has her control been?
  • Any evidence of end organ involvement?
In EHR to go graphs>> BP >> see that she is usually <140/80 over last 4 years
Chart review >> Cardiology>> Echo >> none, EKG >> normal (no evidence of LVH)
Chart review >> Lab results >> BMP>> Creatinine normal, K normal; UA >> no Hb or protein.

Create agenda: Ask about home BP measurements, does she have a machine, do cardiovascular exam for murmur, gallop, heave, bruit, pulses and look at fundus.

The student looks at me amazed!  She did not know the EHR could hold the answers to so many questions. I tell her how she can create her own agenda before going into the exam room.  Once she has elicited the patient's agenda and addressed it, she needs to cover the items on her own agenda.  Hopefully both the agendas are the same.  Hopefully there is time to cover both the agendas.  

We have spent 30 minutes discussing and reviewing all these issues.  We are lucky we got an early start and the patient was late!

So what is the point of this story?
1.  EHRs can hold an amazing amount of important information
2.  Getting this information out of the EHR takes a lot of time, clicks and knowledge of where to find this information.
3.  These benefits are visible when all the data is in one system.  If the consultants and labs and imaging were all done at different places, this would not be possible.  Even when external reports are scanned in, this data is not easily accessible.  As we develop electronic data interfaces this should not be a problem.
4.  Some patients expect that just because all the information is in the computer, it is also in the physician's brain!  Wish they could realize how much effort it takes to dig all this information out.
5.  As physicians use EHRs and spend time reviewing and summarizing the information, they should take time to encode it in a way that makes it easy for the next provider or the subsequent visit.
6.  Students learn how to get the history from the primary source but will also need to get comfortable getting the data from the EHR in a meaningful manner.  While looking up the information in the EHR prior to talking to a patient can create a huge bias and a kind of filter bubble, it is a great way to look up chronic problems.
7.  The time that it takes to review all the information occurs outside the exam room and it can become non-reimbursed care.  Doing this review is very important for patient care.  Will this become a non-issue once we move to ACO's?