The art of medicine: It’s still personal

“We have to be invested in our patients.” It’s our chance to connect in meaningful ways, says Martin McClintock, MD, a family physician in the St. Louis, Missouri, suburb of Ballwin.

After 30 years of practice, McClintock knows. He describes his role as family physician as part educator, part confidante, part actor to help patients change behavior, and part healer.

Developing and strengthening this bond with patients is truly the art of medicine. It’s built by listening, by communicating, and by caring.

And not one of those roles, McClintock adds, has anything to do with typing notes into a computer.

For McClintock, maintaining a very personal connection with patients during an encounter has been an ethos guiding his career, and it simply was not negotiable when his solo practice made the decision to adopt the practice’s first electronic health record (EHR) system using Amazing Charts.

His first decision regarding implementation of the EHR system was one of the easiest, he says: he did not want to work on a computer during a patient encounter.

And his patients agreed.

“The months before implementing, I was going to try to bring the computer into the exam room. One of my patients said, ‘I can’t stand talking to my doctor while he is typing into the computer. He spends more time with computer than he does with me.’ ” For McClintock, it was enough said. And although the computer lock-out is contrary to what many practice management consultants advise for many office-based practices, McClintock and his staff of two nursing aides have found a way to make it work.

In just 1 year, his practice not only achieved meaningful use; it also improved revenue by 5% last year, excluding government incentives.

As a participant in the Medical Economics EHR Best Practices Study, McClintock talked about how he and his staff organized the practice, as well as his approach to implementation and use of the EHR system.

Anatomy of the practice

Ballwin is considered a second-ring suburb of St. Louis, with a population of about 30,000. From the surrounding area, McClintock has a patient base of 10,000, but far fewer appointments are scheduled every year. His client base is about 35% to 40% Medicare in an area that has grown with urban sprawl around the St. Louis area.

Although McClintock says his caseload has not increased, patients are calling and coming into the practice with multiple complaints-more so today than in the past. On average, McClintock schedules 30-minute appointments to address those problems. The family physician deals with everything from bronchitis to manic depression-sometimes during the same appointment. His patients are newborns to grandparents and every age in between.

The complexity of the cases, McClintock says, is another challenge in documenting the encounter.  He believes it confounds working in an EHR during the information gathering stage of a patient encounter.

“I may get about 1% of the necessary information, and the patient jumps to the next problem and offers about 10% of that information and then skips to problem three, etc.,” he explains.

The result, he says, does not necessitate a smooth experience when using the pick list fields within an EHR. McClintock, on the other hand, simply broke rank with the advice of many of experts on the subject of actively using the EHR during an encounter to document the patient visit as it is occurring. He handwrites his encounter notes and simply transfers them to one of his nursing aides to type into the templates that he and his staff designed. He reviews the accuracy of the note at a later time.

In relation to other business processes, invoices mostly are generated by the office and mailed to patients for remittance. The practice does not accept credit cards, simply because the charges associated with credit card fees are too expensive for a small practice to absorb, he says. Like many small solo, office-based practices, McClintock remains self sufficient, and the staff members all share responsibility for the front-office and back-office functions.

Implementation

When it came to the implementation of the EHR system, the practice began using the software December 5 and went live a week later.

As part of the Medical Economics EHR Best Practices Study, McClintock received the software for use for 2 years. Associated costs of the implementation, however, ran about $3,000 in hardware and some information technology support. The dreaded go-live date was anything but dreaded, McClintock says. He describes the implementation as quite simple.

“I have read the stories about loss of productivity and all the problems associated with go live. We didn’t have any of those issues,” he says. “I am the furthest thing from a computer geek, and we got this up and running very quickly. Go live was not a big thing,” he adds.

Although McClintock and his team did not scan his patient records, they still maintain paper charts.

The system boasts of broad capabilities for charting, scheduling, messaging, e-prescribing, billing, creating templates and working off site, but McClintock says that combining the technology with a traditional paper-based approach remains an acceptable and efficient way for the practice to operate.

He is not working off a dedicated server, but the vendor does recommend doing so for practices with three or more physicians.

McClintock jumped into the digital age on a shoestring budget. And he didn’t do it for the efficiency gains, but because of the government’s incentives and penalties for not using EHR systems.

The practice’s success, however, shows that even a very small practice on a tight budget can make implementation work, he says. And he couldn’t have done it without the help of his two longtime nurse aides, McClintock says. In fact, after reaching meaningful use, McClintock shared the bonus with them.

“I might see the patients, but we run this practice as a group, and I think that is why we have worked so well together for 28 years. It is because they have a lot of responsibility around here, and we work together.”

McClintock and his staff have found the balance between adopting technology and applying it in ways to protect the bond he has built with his patients over decades of practice. And EHRs have advantages, the key is adapting the technology to work within the parameters of the practice, McClintock says.

And although many of the EHR systems are expanding features that include clinical guidelines and decision support, McClintock cautions physicians to never lose sight of their instinct and the art of medicine.

Breaking down barriers

Some electronic health record (EHR) system features are so distracting they can prevent the physician and patient from having a meaningful personal interaction.

In fact, multiple surveys have shown the shortcomings of EHR systems as they relate to the many ways physicians interact with patients and use a system during an encounter, according to a report from the Office of the National Coordinator for Health Information Technology (ONC).

The problem, the ONC reports, is that the physician becomes so focused on filling out check boxes and navigating within the system that he or she fails to communicate effectively or ask pertinent open-ended follow-up questions to patients during an encounter.

So what is the solution? Consider strategic placement of an EHR workstation so the physician can maintain eye contact and work in collaboration with the patient.

David Judge, MD, of the Ambulatory Practice of the Future at Massachusetts General Hospital in Boston, told Medical Economics that he invites patients to sit at a shared computer station so they can work on the document together. Not only does it break down barriers, it lets the patient become an active participant in his or her care by helping to document the accuracy of the information and build a treatment plan.

The ONC also outlines these patient engagement activities:

- viewing medical records and key medical data;

- conducting transactions with providers, such as secure messaging, refilling prescriptions, and scheduling appointments;

- accessing medical knowledge and health information materials;

- managing personal health information (for example, blood pressure, weight, etc.); and

- receiving decision support for healthcare and health management decisions by participating in health-related online social networks.