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Shining a Light on the Dark Side of Health IT's Irreversible Adoption

By John Reichard, CQ HealthBeat Editor

September 28, 2012 -- Unlike several years ago, there's now little doubt that health information technology will be widely adopted by doctors and hospitals. And among pace-setting medical practices that deliver team-based care, there's no question about its power to cut costs and improve health.

But there's a dark side: Doctors face burnout from working longer days because of IT. And the time they spend staring at their computer screens during office visits, rather than giving their patients quality face time, undermines good care.

Those were the takeaways from a Capitol Hill presentation by a panel of experts that reviewed where doctors are now in adopting electronic health records and other health IT, and whether it's actually delivering on its promise.

Perhaps the most startling statement was made by Christine Sinsky, an internist with the Medical Associates Clinic in Dubuque, Iowa, one of a panel of speakers that otherwise strongly touted IT's benefits. The event was sponsored by the nonpartisan Alliance for Health Reform.

"It's this issue of continuous partial attention," she said. Undivided attention "is the essence of good care," but because doctors spend so much time looking at computer screens entering data while the patient sits nearby, "we have been crowding out some of that essential interaction," she said. "Work that used to be done by the transcriptionist, by a receptionist, by a billing clerk, by the pharmacist, much of that work has now been transferred to the shoulders of the physicians and the nurses on the clinical team. And that has become increasingly unsustainable.

"In fact, I'm concerned that we risk losing the majority of our time together with our patient on data entry and clerical kinds of tasks."

Sinsky, who also is an IT consultant, said that over the past several years she's visited more than 40 doctors and nurses in different innovative medical practices around the country that are on the front edge of delivering new models of care. "Almost uniformly, primary care physicians are taking two hours of in-box work home to do every night after their children go to bed. I think this has profound implications for career satisfaction. And that, in turn, has profound implications for the primary care workforce of the future" and its ability to deliver better care at lower cost for the nation, she said. "We would never go back, but we have to keep moving forward. We can't consider that we're there yet" on living with the new technology.

Sinsky's comments struck a chord with another speaker, Andrew Racine, chief medical officer at the Montefiore Medical Center in the New York City borough of the Bronx.

"I am so happy that Dr. Sinsky's here, because she has raised one of the most critical points with the regard to the use of this technology at the exam room," Racine said. "You just simply cannot do what you used to do when you're using a computer versus doing something on paper."

Their comments were notable because they otherwise stressed how key IT has been to improving the health of their patients. Racine said that in the Bronx, the poorest county in the country, IT has allowed better sharing of results among doctors in the Montefiore system of newborn screening, assessment of mental and emotional health of toddlers and school-age children, and screening for sexually transmitted diseases among adolescents. Improving population health is "really what the promise of this technology is all about," he said.
Sinsky described the "bumpy road" with health IT as a solvable first-generation problem.

she said the new, powerful technology "demands a new delivery model, and it demands a different model of support staff," she said. "It cannot be a physician and a patient and a computer in the room alone."

Sinsky said she would love to see community colleges "ramp up their training of associate's degree RNs and other clinical support staff who've had specific training in information management" to enter that data during office visits.

She also said that some of the practices she's visited have adopted a model in which a medical assistant or a nurse will join the physician in the room and help with documentation. "That has been one of the stronger new models that we have identified."

Sinsky did say that the electronic health record has been one of the essential components in making her clinic one of the nation's top performing health systems. It's much easier to share information more rapidly with patients, she said. "So whenever a patient leaves my office with a change in medication we give them an updated medication list. So they're much less likely to have confusion, or make an error around their own medication management." Also, "we do test tracking, so it's very uncommon for any test to fall through the cracks and not have been reported back to the patient. We want to leave nothing to chance in the care of our patients."

Sinsky added that she fully supports the recent stage two "meaningful use" rule issued by CMS but objected to its prohibition on reception staff doing the physical keyboarding of orders for lab tests and X-rays.

Farzad Mostashari, the National Coordinator for Health Information Technology at HHS, delivered an upbeat assessment of health IT's adoption.

Extension centers that help providers adopt health IT throughout the country are now working with 147,208 primary care providers, he said. Seventy percent of small doctor's offices in rural areas are working with the centers to adopt IT, he said. Mostashari expressed hope that close to half of the health care delivered in the U.S. would soon be from providers using IT systems.

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