Recently I met a guy who raises cattle on his family’s ranch. It turns out that the whole cattle business is much more complex than I realized. Who knew that cows were trainable and that certain ones were more playful, gentle, irritable, or curious than others?
My cowboy friend also explained there were several methods for “calling in the herd” when cattle needed to be moved to a new pasture or just “herded” up for feeding. He preferred the bucket feed method, which involves driving up with a bucket of feed. Like dogs, the cows are food-motivated and will move towards the sound of a shaking bucket, even if it’s in the next pasture.
Cowboy Friend also explained that other folks preferred to use herding dogs to move cattle, and still others were partial to “cutting” horses.
Who knew there could be so many seemingly “right ways” to accomplish similar tasks?
The same rhetorical question popped into my head when visiting my family practice physician last week. Last year during my annual physical the practice had just gone live on a new EMR system and the doctor had accessed my records from a computer in the exam room. I loved the experience because there was a large monitor on the wall and I could see everything the doctor could see and read what was being entered.
During the latest visit, however, the doctor never accessed the computer in the exam room, though his medical assistant did. The doctor instead had what appeared to be a one page summary with my history and most current vital signs. After the exam he walked out and I could hear him dictating.
As I was walking out I asked his medical assistant why the doctor didn’t use the computer in the exam room. She said that “he believes that when he is with the patient, his sole focus should be on them and he doesn’t want to be typing away at a computer or have his back to patients.” She went on to explain that he didn’t want anything to interfere with his treatments or care.
His group has one of the big-name EHRs. I am a fan of their patient portal but unfortunately my doctor only includes lab results and a health summary in the online chart. Since I haven’t (yet) requested a copy of the doctor’s note, I am not sure what he included in the dictation, so I can’t make a judgement as to the quality of the final note. However, I can confirm my doctor sat right in front of me and looked me directly in the eye as we discussed all my health concerns. I felt as if he was fully focused on me and I had his full attention.
Of course I love the potential of EHRs, so I couldn’t help feeling a little disappointed that my doctor had abandoned point-of-care documentation because he believes it interferes with patient care. What if he missed some sort of critical warning message in my chart? I mean, he clearly failed to notice (or, more likely, cared) that I had gained five pounds in the last year. But seriously, what might he have missed because the electronic chart was not right in front of him?
The reality is that I am healthy, so I’m confident that he didn’t miss anything critical. I’m sure the new chart note was complete and that my health was not impacted by his documentation style. In other words, as my doctor has discovered, there is more than one “right way” to accomplish the task of documenting a patient encounter in the EHR.
Which begs the question: if there are multiple ways to document a patient encounter without compromising safe and effective care, why does the Meaningful Use program mandate certain workflows rather than mandating the end result? Shouldn’t it be more important for practices to complete these tasks, regardless of their methods?
For example, a few months ago a CIO shared with me that his physicians had always done a great job providing patients with educational materials. However, in order to meet Stage 2 Meaningful Use requirements, this activity had to be noted in the patient’s chart. The CIO was frustrated that even though his practice had always been diligent in addressing patient education, the doctors had to modify their workflows – and most felt the new way was less efficient.
I also asked Steve Waldren, director of the AAFP’s Alliance for eHealth Innovation, for his thoughts on the subject. He acknowledged that many AAFP members have shared similar concerns over Meaningful Use rules that require providers to accomplish certain tasks in particular ways, even though a mandated workflow doesn’t necessarily improve patient care. He pointed to the “Record Smoking Status” objective, which requires users to note smoking status in the EMR in order to receive Meaningful Use credit – even though many practices have always captured this same (or more complete) information using alternate methods, such customized patient history forms.
I’ll have to ask Cowboy Friend how flexible old cows are when it comes to learning new tricks. I’m sure it can be done, just like I am sure that there will always be some cowboy out there who believes his cattle–herding method is superior to all others.
Lucky is the cowboy who gets to herd his cattle by whatever “right way” works best for him and his cows.
Michelle Ronan Noteboom
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