Home Forums Discussions General Discussion Where to from here? Wants and Needs!

I am always excited when I have a few moments to browse this forum and I see the mix of clever work arounds and fantastic ideas that the forum members are talking about.

But...

On a recent whim I bought a digital book called "Medical Charting Demystified". It is a nursing text, and really pertains to the hospital record, not the office chart but I was right when I suspected I could learn a thing or two from a different perspective.

Nursing notes in the hospital setting are structured for an entirely different purpose,... except basically it is all about patient care.

The first thing that struck me was the utility of the "kardex". A single page that brings the total of the patient care plan into focus in one place. The second thing that has impressed me is the probable utility of verbalizing what the goals of treatment are.

Stating the goals may not seem like a big thing, but I suspect it is. We all have the same goals, ie: diabetic patient needs HgBA1C < 6. OK fine, but how do you get there? The first patient you see today may have a HgBA1C of 8 and is still very ignorant of the proper diet and is only taking metformin, but still drinks 32 oz of Pepsi and is sucking on a cough drop as we speak. Our goal should be diet education, but where is that charted except in the plan for one days visit? When the patient returns for a cough, cold, annual exam, sprained ankle etc the plan is interrupted and we have the potential to drop the ball with respect to following up aggressively on the plan. 250.02 in the problem list is neither a plan nor a short term goal of treatment.

The second patient with a HgBA1C of 8 is already on Basal and Bolus and while he or she will certainly benefit from any additional diet education we can provide our more immediate goal should probably focus on gathering data to allow us to fine tune the coverage of carbs with the bolus dosing. Education will concentrate on how to count carbs.

Stating these goals, and making this data in some way granular would allow us to quickly find the candidates to attend a class when it becomes available, and it would make it much easier to stay on task when the patient is in the office using up those very precious 10 minutes of the visit.

Using rich text format, or improving the Rolodex are clearly valuable tools or bells and whistles that we would all love to have available, but the future of medicine will be forever changed when we learn to shape the medical record into a tool that facilitates our ability to efficiently apply knowledge to the entire practice, (the database).


Last night I attended a lecture on diabetic care provided by our IPA which coincidentally provided bonus checks to the practices with good outcomes in this area. The stick and carrot was employed as we got a check, and a list of the patients with big deficiencies in this area. I was shocked to see that I have some, (many are patients who never come in to be seen) with really bad numbers. I would have sworn I had no more than 6 patients with HgBA1C over 9. And two of those six are new diagnosis. But I am ignorant of the ones who never come in, but have been to an urgent care or ER and had a lab value come up with a glucose that is elevated etc. I have work to do, and the EMR is a great tool to assist in working on these patients, but it could be so much more. In the traditional model of care, we got paid for the 10 minutes, and any patient who does not come in to the office was really no responsibility of ours. In the IPA model of practice there is some money, (the bonus, P4P money) that will reward efforts on behalf of the non-compliant patient. We have to expand on this part of our practice. Society demands it, and when we find a way to deliver we will also be able to find ways to be paid for our effort.

We really are standing in the threshold of a change in our practice that will be even greater than the impact that Larry Weed, M.D. had in 1968 when he advocated the "Problem Oriented Medical Record" which ushered in the entire concept of chronic care.

The "Outcome Oriented Medical Record" is evolving and I believe it will flourish in the small EMR where innovative physicians apply themselves to the problem of making the power of the computer tackle the concept of "treating" the database.

Well said, Martin. I am also looking forward to outcomes driving medical practice.

However, I have to comment on another aspect of the restructuring of medical practice -- a factor that is rarely addressed -- patient responsibility. I'm sure that all of us are frustrated at spending time instructing, convincing and cajoling the patient with HgbA1c of 9 or the BMI of 35, only to confront the same issue on followup appointments, complete with the excuses, disinterest or hostility. Will physician incentives change the non-compliant patient?

Perhaps the carrot & stick should be used on the patient side of the relationship. Get a note from your doctor to buy a bag of M&Ms. BMI over 30 must park in the farthest parking lot at the mall. Missed appointment...health insurance premium goes up 10%.

Kindness and empathy don't seem to be working.

Actually, those are great ideas, John.

John you are right on! But the job is still ours, and the challenge is to find what works. Glen Lopez at UCLA has spent a lot of energy trying to get his patients to walk. HTN, DM, and obesity? NOBODY would care, when he finally hit on, "come join us and meet your neighbors, spend quality time with your family and get your children away from video games" it resonated. Last time I spoke with him he had 2,200 patients walking one hour a week in walking groups with an average attendance of TWO YEARS. A stunning achievement that will net a huge reward in his practice area.

In my opinion we have such a wealth of real talent in this users group, I would love to see the result of our collective attention being focused on the model of practice for the future.