A Country Doctor Writes:

Warfarin dosing requires viewing past values and past dosing. If every time a certain dose change results in an unwanted result, we should probably avoid making the same over- or under-correction again and again.

For many years I have used a paper(!) flowsheet that takes seconds to utilize and gives a practical overview. These sheets sit in a three ring binder. My nurse can flip through this binder and spot who is delinquent with their testing. The actual lab values are of course in the computer, but so far the three EMRs I have used can’t give me the overview I need within anything even close to a reasonable timeframe.

These two pictures say it all. My patient in the paper flowsheet has a home INR that requires weekly testing for the insurance to cover it. The “workflow” (how I dislike that word) on the bottom is from Epic.

I thought computers had the capability of speeding things up, but in my corner of the world that is mostly a pipe dream.

It’s all about inflammation, from cancer to Alzheimer’s disease and arthritis, colitis and psoriasis in between. And now we hear the brain controls inflammation via the vagus nerve.

A couple of years ago I wrote about how the vagus nerve regulates mood and emotions. Now The Wall Street Journal writes about how it controls our immune responses. I had a professor in medical school who used to say “if you know lupus, you know medicine”. Maybe at this point in time one might say “if you understand the vagus nerve, you understand medicine”.

According to an interesting article in the Wall Street Journal the other day, a decades old discovery that the brain regulates the immune system through the vagus nerve is promising possible new ways of treating what seems to be the root cause of many chronic diseases.

Electricity Is the New Medical Miracle

“Dr. Tracey’s break­through two decades ago was the dis­cov­ery that the brain also con­trols the im­mune sys­tem through the va­gus nerve. By us­ing elec­tri­cal stim­u­la­tion to hack into neural net­works, it’s pos­si­ble to reg­u­late the im­mune re­sponse and per­haps some­day cure in­flam­ma­tory con­di­tions such as mul­ti­ple scle­ro­sis, lu­pus and even Alzheimer’s dis­ease.”

https://www.wsj.com/amp/articles/electricity-is-the-new-medical-miracle-crohn-vagus-nerve-biotech-startup-trial-remission-treatment-11658512502

The other day, as we were both struggling to pull off a visit every 30 minutes with a brand new EMR following a very cursory onboarding, Autumn told me a new nurse coordinator had called and said Mr. White was due for his annual urine microalbumen test.

He had just left the office. I shrugged and said “I had all I could do just to import his medications, vitals and even the assessment and plan into his blank office note. If whoever she is knew he was due, she could have entered the order if we had a standing order. I’m a problem solver, not a bookkeeper”.

Later that day, waiting for my dinner to cook, I picked up last week’s The New England Journal of Medicine and noticed an article by Christine Sinsky and Jeffrey Panzer about exactly this kind of issue.

In The Solution Shop and the Production Line, they make the case that doctors shouldn’t be the ones held responsible for things that can and should be automated. Our time and effort should be more directed toward relationship building, diagnostics and treatment planning.

I think the bookkeeper analogy is perfect. I believe it is a consequence of non-clinicians trying to understand what we do and failing to grasp the complexities of medicine. Our training and our temperaments are focused on diagnosis and treatment. With all the computer power involved in healthcare these days, why does anybody think it is appropriate and cost effective for the physician to enter annual orders from memory or at the command of nurses who could easily do that with standing orders in place.

No wonder we have a perceived doctor shortage in primary care in this country: We are too often asked to do bookkeeping tasks at the expense of intellectual, clinical, educational and motivational efforts for the benefit of our patients.

Dr. Sinsky knows this. Her job at the American Medical Association is to fight physician burnout.

It can’t be said enough: The root cause of physician burnout is that we are required to do and evaluated for excessive amounts of non-physician work in today’s healthcare environment.

The Root Cause of Physician Burnout: Neither Professionals nor Skilled Workers

It was a Microsoft déjà vu: It was late 2019. Our clunky 18 year old EMR was not going to be supported anymore. We had a choice between Greenway’s “new and improved” product, Intergy, and starting over with something new. I cast my vote on eClinicalworks, a fairly simple product I had used in Bucksport. The conservative choice was to stick with the company we knew, so the decision was Greenway’s Intergy.

2 1/2 years later we were still limping along at half our previous productivity level and working without even a laboratory interface with the hospital that does the vast majority of our tests. Our providers were scrolling down endless lists to choose lab tests and x-rays with no search capability in the EMR that was supposed to be more modern.

Our suffering is now (supposedly) over, but replaced by the pains of starting over with something very different. We moved to Epic. One obvious advantage is that the hospital will have the same system, so there will be an interface. But I had heard comments like “working with Epic is like taking a semi to buy a quart of milk at the corner store”.

I have said this before: EMRs today are like VHS and Betamax of yore 100 times over. No inter-operability, and everybody waiting to see which format will become industry dominant, I am told.

So here I am, fumbling around in a system that may become the dominant player if it isn’t already. My first impression after a couple of weeks is that it really is a very large vehicle for the mostly simple errands I handle, and more complex than I need it to be. It is a funny mixture of unnecessary flexibility and annoying rigidity.

The flexibility is downright ludicrous: The system doesn’t import my assessment and plan into the office note by default. Why would anybody practicing medicine on planet earth not want that included in their office note?

Worst of all from my brief experience is the same as in other systems: the doctor is the first one to see the incoming reports, labs and imaging. It is a classic dilemma in electronic health records. I liken it to having the president open his own mail.

This new system supposedly helps me work smarter in terms of remembering who needs to go on aspirin and whatever, but it sure doesn’t let me use my team members to sort and prioritize information for me. That is a universal problem with healthcare today.

All the President’s Mail