The Status of Physician Computing

BY DR. ALAN BROOKSTONE
(Republished from Canadian Healthcare Technology - September 2003)

Despite the hype surrounding technology as an enabling medium and evidence that medical errors could be significantly reduced and health care delivery improved, the number of physicians using computers as an integral part of their practice is still relatively low.

In July 2003, I had the privilege to lead a technology cruise conference to Alaska aboard the Royal Caribbean Radiance of the Seas.With three faculty and 27 participants from the United States and Canada,
the conference covered a range of topics, from PDAs to electronic medical records and medical uses of the Internet. The conference also provided an opportunity to reflect on the status of physician computing today. How far have we progressed in terms of the use of electronic medical records, clinical decision support and electronic prescribing? My impressions are as follows.

A presentation on E-mail communication between physicians and patients prompted lively discussion. U.S. physicians are beginning to use e-mail as a professional communication tool, more so than Canadian counterparts. This has some cost-saving advantages, particularly in the managed-care setting, as a mechanism to keep patients out of medical treatment facilities. However, security and privacy concerns are still at the forefront as barriers to more extensive use of e-mail to communicate both with patients and
other physicians. Approximately 50 percent of conference participants used PDAs as time management
and clinical reference tools. These numbers are growing consistently, indicating a degree of maturity in both the hardware and the range of clinical applications now available for the PDA. The majority of users still use Palm OS products due to ease of use, low cost and the wide range of clinical applications. Has the increased
use of PDAs spurred a corresponding use of other forms of technology?

My impression is that physicians overall are far more comfortable with technology than they were two years ago. Because of the low barrier to entry, the PDA has been an enabling technology even for physicians whose overall computer skills are limited. For the majority of physicians, the value proposition to move to an electronic medical records-based practice is still not clear or easily quantifiable in the context of their individual practices. Instability in the EMR vendor market, lack of clinical data interfaces to key sources of information such as labs and imaging, security and the high costs of equipping a practice, were still identified as significant barriers to entry. Although greater numbers of physicians have access to one or more computers in their practices, most are not using computers at the point of care.

In order for computers to be effectively used by physicians as clinical tools, the electronic environment needs to mirror the work environment more effectively. In other words, the environment needs to become richer – more interfaces with outside sources of data, a wider range of clinical decision support tools and secure high speed networks using encrypted e-mail to connect physicians. The sharing of information will not take place until ‘last mile’ connectivity is ubiquitous.

There are some bright lights on the horizon. Tablet PCs have improved since first generation devices were released. Battery life, screen size and resolution and processing power have all improved. In combination with faster wireless networks, computing power is moving closer to the physician’s hand. PDAs and telephones are converging into smart telephones, providing voice and wireless data services such as short messaging, mobile e-mail and Internet access.

Comments

[Alan Brookstone for Thomas W Bauer]

The following comment is published on behalf of a non-physician colleague. I believe the question is one that applies to many groups of professional providers in terms of the way that patients will be able to book appointments in the future.

This is a great site. Since this is my first visit I would like to thank Alan for putting this together for all that are considering the implementation of EMR into their practices.

I have a question for everyone:

Has anyone considered the use of an online appointment scheduler? Although it doesn't integrate with my billing software, it would give my patients a chance to book their own appointments.

[fred freedman]

Yes, I read something about a clinic in Ontario doing that in, is it Technology for Physician? Alan in an editor so he can tell you.
The doctor quoted in the article liked the system but I personally can not see how an algorhythm could be written to take into account all the different issues when booking appointments. For instance everyone must have patients that always need longer appointments.
Of course, as an HSO, it isn't necessary for us to see patients for billing purposes and so we can deal with a number of things by phone.

[Scot Mountain]

Our ASP EMR allows us to do this already, although we don't have any patients that have subscribed to the service as yet (there is a fee for their access).

The physician and clinic can get specify who is allowed to book their own appointments online, and what appointments are available online, so that patients who consistently need extra time can be forced to book through the receptionist as per usual; this is all integrated with the billing module.

The idea is to take pressure off the phones, so that patients that do need to call in can get through when they call. I will let you know how it works when we get patients using it.

[Alan Brookstone]

This is a very interesting subject. I was waiting for some commentary from physicians before I added my thoughts.

I initially was very against allowing patients to book their own appointments online, however I have changed my thinking (with some conditions). It is likely that a patient would book an appointment through a link to the office system from the medical practice web site. Therefore guidelines for booking could easily be posted in a place that patients would access before actually requesting an appointment.

The next issue is how much space could be freed up to allow patients to book and what appointments might be appropriate. This depends on the practice profile and physician style, however if it were possible to allow patients access to a limited number of appointments per day for specific indications, then I would have no problem opening up the time. The key is to define what is acceptable, make only those appointments accessible through online booking and communicate the information back to the patients in the practice. This provides a higher level of service and the poilicies can always be modified if it is found that patients are booking inappropriately.

So my steps would be: 1. Think it through 2. Decide on how many spaces and what type of spaces to make available 3. Evaluate for a period of time e.g. 3 months 4. Adjust the booking process based on the evaluation and implement the changes to continuously refine the system. This will need to be a dynamic process, but one that could pay efficiency dividends in the future.

I look forward to other physicians' thoughts in this area.

[Thomas W Bauer]

Fred

You say your ASP EMR does this already, but for a fee. This fee is supposed to be paid by the patient?

[Scot Mountain]

Thomas,

Yes the fee is paid by the patient. The idea is that they gain benefit by having access to scheduling outside clinic hours, and without having to wait on hold in our phone queue. Other services can also be made available to them at the physician's discretion, including online Rx refills, access to basic chart information such as diagnoses, current meds and doses etc.

As I noted previously, we have not had any patients sign on for these services yet. If you are interested, if and when we do get some uptake I can let you know how it works.