Trying to plug innovative ideas into legacy structures

We are in the midst of reworking our processes associated with the flow of patients in ambulatory practice. We have the laudable goal of making the process more functional and better at actually meeting patient goals. It is unquestionably the right thing to do. However, the devil is always in the details.

We have examined how we interface with patients, what information we need to collect for financial reasons and what information we need to collect for compliance reasons. The key driver of this is the Federally mandated meaningful use of EeMR. As an afterthought, we are also considering what information we need to collect for diagnostic and management issues particular to specific encounters. 

When assessed prospectively, the amount of information that needs to be collected and inputed in a structured way in the ideal world is mind boggling. The question is whether this task actually be accomplished in the very brief scheduled encounter times which are part of outpatient practice? However, perhaps the more relevant question is why we would even try to do this in the first place.

Within the context of re-examining our work flows, we seem to be examining virtually all assumptions except one; the encounter based model where everything must and should be done within a ridiculously brief encounter. While I may have major disagreements with our soon to be former CMS Chief, I completely agree with Don Berwick in that our encounter based model of delivering medical care is a problem.

There is absolutely no reason that virtually all information which is now extracted by asking patients in the office could not be done prior to the visit, and I am not talking about five minutes ahead of time. Who knows better than the patient what medications they are actually taking and what better place for them to address this question than at home in front of the very pill bottles that their medications come from? Why should we wait for them to come to the office, charge costly personnel with the task of trying to sort this out until severe time constraints, and then input what could have been inputed by the patient, more accurately, and at lower cost?

The same goes for virtually any piece of information where the ultimately source of the information is the patient. New complaint? Old complaint with ongoing symptoms? In each case, relying on a member of the medical team to ask the right questions, listen effectively, remember what is important, and record this accurately, all within severe time constraints is simply a formula for error generation. For most patients and their needs, off loading these tasks and information collection to a time where the tasks can be done with fewer time constraints and by someone more vested in getting the right information loaded simply makes sense.

Until we re-examine the utility of using brief encounters as the underlying architecture of ambulatory care delivery, all the problems of information collection, data entry, and ultimately effective problem solving will remain sub-optimally addressed.