As medical practices and health systems adopt new information technologies, the doctor-patient relationship is beginning to change. Some doctors say Electronic Health Records allow them to spend more time addressing patient concerns during visits. And a growing number of health systems are using email and custom apps to stay connected with patients between annual checkups. But new technologies can also create headaches for doctors and patients. Kojo talks with a panel of doctors about the ways technology is impacting personal health care.

Guests

  • Alice L. Fuisz MD, Internal Medicine Physician, Washington Internist Group (DC); Governor, American College of Physicians, DC Chapter
  • Nareesa A. Mohammed-Rajput MD, Internal Medicine Physician and Physician Lead for Electronic Medical Records, Johns Hopkins Healthcare
  • Ted Eytan MD, Director, Kaiser Permanente Center for Total Health, The Permanente Federation, LLC
  • William Yasnoff MD, PhD, Managing Partner at National Health Information Infrastructure (NHII) Advisors; CEO and President at Health Record Banking Alliance

Transcript

  • 13:06:38

    MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. The doctor/patient relationship used to be a decidedly low tech affair. You'd see each other once or twice a year, exchange pleasantries and small talk. They'd run some tests, scribble something illegibly into a paper folder, and with any luck, you'd be on your way, free and clear until the next checkup or sinus infection.

  • 13:07:15

    MR. KOJO NNAMDIToday, that relationship is getting a high tech reboot. Some doctors' offices have gone entirely digital, tracking patient histories through electronic health records, using technology to engage their patients in new ways during visits. And continuing the conversation over email in the days and months between visits. But, those same technologies might also drain the human element from the doctor/patient relationship. This hour, we're exploring how health IT effects the patient experience with four local doctors and technologists.

  • 13:07:47

    MR. KOJO NNAMDIJoining me in studio is Dr. Ted Eytan. He is Director of the Kaiser Permanente Center For Total Health. He's a board certified family physician, but today, he works with large health systems and technology experts to explore how health IT can be used to engage patients. Ted, thank you so much for joining us.

  • 13:08:06

    DR. TED EYTANThank you.

  • 13:08:07

    NNAMDIAlso with us in studio is Dr. Nareesa Mohammad-Rajput, Internal Medicine Doctor with John Hopkins Health Care. She's also the Lead Physician Coordinating Electronic Medical Records in the Hopkins Healthcare system. Dr. Nareesa Mohammad-Rajput, thank you for joining us.

  • 13:08:24

    DR. NAREESA MOHAMMED-RAJPUTThank you, Kojo.

  • 13:08:26

    NNAMDIAnd Dr. Alice Fuisz is Internal Medicine Doctor with the Washington Internist Group in D.C. She's also Governor of the American College of Physicians, D.C. Chapter. Dr. Fuisz, thank you for joining us.

  • 13:08:41

    DR. ALICE FUISZThanks for having me, Kojo.

  • 13:08:42

    NNAMDIAnd also in studio with us is Dr. William Yasnoff. He is Managing Partner at National Health Information Infrastructure Advisors. That's a consultancy firm. He is CEO and President at Health Record Banking Alliance. Bill Yasnoff has a PHD in Computer Science and previously served as a Senior Advisor for National Health Information Infrastructure at the US Department of Health and Human Services. Dr. Yasnoff, thank you for joining us.

  • 13:09:09

    DR. WILLIAM YASNOFFPleasure to be here.

  • 13:09:10

    NNAMDIYou, too, can join the conversation. Give us a call at 800-433-8850. Do you consider your doctor to be tech savvy? How has technology impacted your relationship with your care provider? 800-433-8850. You can send email to kojo@wamu.org. You can send us a tweet at kojoshow. Or simply go to our website, kojoshow.org. Ask a question or make a comment there. Nareesa, I'll start with you. In many ways, the typical doctor's appointment could be a case study in time management.

  • 13:09:45

    NNAMDIAs a patient, I've got to take a couple or three hours off from work. I usually find myself waiting at least 20, maybe 30 minutes when I do finally get into the exam room and talk with the doctor. I need to receive and transmit a whole lot of information in a very short period of time. Sometimes as little as eight or nine minutes. Put on your primary care doctor hat. Walk us through a typical appointment. How has technology effected the way you conduct or consult with a patient?

  • 13:10:15

    MOHAMMED-RAJPUTSo, when I first walk into an office, and I know that, you know, first things first is that I'm walking into a room and if you're not my first patient of the day, there's a chance that I'm already behind. And so, I want to make sure that I try to address that your needs are being met and that if there's anything that I have done to upset you, at that point in the day, to make sure that I try to make -- that your pa- the patient is OK. And then I try going to what can I do to help you? How can I help you be healthier?

  • 13:10:49

    MOHAMMED-RAJPUTHow can I deal with and look at the information that is making you who you are? So, for example, I walk into a room and I will see my patient. And what I like to do is I like to form a triangle between myself, the patient and the computer. And the reason for that is because I feel like what I'm looking at is the same thing that you as the patient should be looking at, so that we can make informed decisions together. And so, we, I go through the chart together with my patient. And so, whatever I'm looking at, they're looking at. If I'm looking at labs, they're looking at labs. If we're looking at tests that have been done, or tests that need to be ordered, we're doing it together.

  • 13:11:26

    MOHAMMED-RAJPUTAnd so, I will walk through the chart as I -- what I'm looking at with the patient to make sure that what I'm looking at is accurate information. Because if I don't have accurate information, then I cannot make a good decision based for you, the patient. And so, it takes a lot of time, you know, to go through the chart, especially if you're on a new electronic record and the date in there may or may not be completely accurate. Because we're trying to move from one system to another. I just want to make sure that what the -- what I see and what the patient sees are exactly the same thing.

  • 13:12:01

    MOHAMMED-RAJPUTAnd that the patient knows what I'm looking at.

  • 13:12:03

    NNAMDIBut is this an isosceles triangle? No. What I'm -- about how much time does that take on the average with a patient?

  • 13:12:10

    MOHAMMED-RAJPUTSo, if I, if it's a new patient to me, it can take somewhere between 10 and 15 minutes, because I'm trying to run through, you know, if the patient has an extensive history, that can take a lot of time. And the reason is because I'd rather invest the time up front to make sure that what I'm making a decision off of is accurate. And so it's, to me, it's time well spent to go through the patient's chart to make sure that what -- the problems that I'm looking at are the same ones that the patient thinks that they have.

  • 13:12:40

    NNAMDIAlice Fuisz, it technology making it easier for you to spend time with patients, or is it just creating new pressures? How do you use tech tools within a personal exam or checkup?

  • 13:12:51

    FUISZMy office went on an electronic medical record back in 2006, so we've actually been doing it a long time. In electronic medical record years, you'd say it's probably a century of time. So we were really early adopters. I think the main, for my practice, the electronic record effects the entire process from the moment you make the appointment, which, these days, might be by sending an email to our office and asking for an appointment. Or calling in to the office.

  • 13:13:20

    FUISZThe electronic record effects that entire process, not just the visits, but all the time in between the visits. So, it allows the staff at the front desk to find your record immediately. There's no longer the need to go and find the file, which might be in a file rack, but might be on the doctor's desk, might be on the nurse's desk, so the record is available the second you call in. And from there, the patient can make an appointment. When I'm actually with the patient, I do the same thing Nareesa does, which is we spend a lot of time looking at the record together, doing medication reconciliation.

  • 13:13:55

    FUISZWhich, if you make the assumption that the patient is on the medications they were on at your last visit, you often are making a mistake, because often, medications have been stopped by another doctor. Or the patient had a problem with it and stopped taking it. There are a whole host of reasons. So, for me, the record, being on an electronic system in the visit, makes a really, makes it much more efficient than it used to be. If you imagine that in the paper record, you used to have a piece of paper for each visit.

  • 13:14:22

    FUISZAnd so you'd flip the chart and on the next day, or the next visit, you'd have -- you'd rewrite the medications, and you'd rewrite a couple of key things from past medical history. Now that's all coming up in the record on the -- on your screen. The historical information moves forward into that day's visit. And all of the phone conversations and email in between visits are there and you can just screen between the different things. So, I think it makes it much more efficient, plus the fact that we're doing a lot of communicating with patients electronically, by email. And I love that.

  • 13:14:54

    FUISZThat, I think, people always wonder if that's a time saver or a problem to have people emailing. What the advantage is -- the patient is putting, in their own words, what they want to convey to their doctor, or what questions they have and I'm answering directly to them. There's no more phone tag, where I'm leaving a message saying, oh, I'm trying to call you about something. I'll call you later. I mean, I used to spend hours playing phone tag with people. Now I know, if I send the message out, they're gonna get it, and then they're gonna respond back directly to me.

  • 13:15:23

    FUISZAnd you don't have the game of telephone where you have the staff person trying their best to take a quick message and what the patient was trying to say to you is not what actually gets through to you. So, for me, it's been a huge improvement.

  • 13:15:34

    NNAMDIIn case you're just joining us, we're discussing how technology impacts doctor/patient relationships and inviting your calls at 800-433-8850. Has your doctor's office adopted electronic health records? How has that effected your relationship with your doctor and how you feel you are being cared for? 800-433-8850. You can send email to kojo@wamu.org. Ted Eytan, whenever we talk about health and technology, the Kaiser Health System usually comes up very quickly. Kaiser is a unique model for delivering care.

  • 13:16:06

    NNAMDIWalk us through the ways technology is leveraged in your typical doctor's appointment, and how that information is used for other points of contact.

  • 13:16:15

    EYTANSure. So, Kaiser Permanente is the nation's largest nonprofit health system. We have about 17,000 doctors and 49,000 nurses. And you talked about completely digital, so that would be us. We're a little bit of the model of how this should work, and it's great to see the other physicians are doing just like we are, and we like to see that. We've changed so much. So, we completed our electronic health record implementation in 2010, which means most of our agents have been on E.H.R.'s for at least three if not 10 years.

  • 13:16:41

    EYTANSo, for us, it's completely changed the way we practice. So, in a typical physician practice at Kaiser Permanente, up to about 70 percent of those patients are already online with us, on our portal. So, we have 4.4 million people accessing kp.org. And what that means is the visit is no longer the only way that you work with a physician. So, we talk about some physicians, in the past, used to say, I only see my patients when they come in. For us, that's just a point in time. So, often, when they join Kaiser Permanente, they immediately start emailing us, having interactions with us.

  • 13:17:09

    EYTANThey see us to get to know us, they have their appointments, they have telephone appointments. But often, as Alice says, a lot happens virtually. And since 2012, it's also happening via mobile phone. So, people can access us that way, as well.

  • 13:17:23

    NNAMDIAnd, Bill Yasnoff, we have heard some sketches of what technology is doing, or could be doing, in the future. And most of the scenarios we tend to hear about electronic health records sound very positive, progressive. But this push is happening as our health system faces massive pressures. We have a wave of baby boomers making major demands on the system. We will soon have a wave of newly insured people who signed up through the Affordable Care Act and need health providers. How important is health IT for addressing those challenges?

  • 13:17:55

    YASNOFFWell, I think it's important to understand that the goal of health IT is not just to have electronic records in all the physicians' offices and hospitals and emergency rooms, and so on. But really, the ultimate goal is to have comprehensive electronic patient records when and where needed. And just having electronic records in all the places where you get care doesn't automatically mean that your comprehensive record is going to be available. And so, the reason this is so important and the reason we should all care about this is that delivering quality care and delivering cost effective care depend on having comprehensive information. This is one of the reasons that Kaiser has been so effective.

  • 13:18:49

    YASNOFFBecause in addition to having electronic health records, they deliver the vast majority of the care for the folks that sign up for Kaiser, so those records are very complete. They're not totally complete, but they're very complete. And that allows Kaiser to deliver more cost effective care, higher quality care. And so, what we really need is a system that allows all physicians and all care providers everywhere to have access to your comprehensive record whenever you show up for care. And, again, just having electronic records doesn't do that.

  • 13:19:29

    NNAMDIWhen people talk about these new health IT systems, I often hear them throw around the word smart medicine, the idea that these information systems will allow doctors to make better decisions and pick up on patterns they may otherwise have missed. Does that mean that the current system suffers from a lot of, well, dumb medicine?

  • 13:19:48

    YASNOFFI don't think I would call it dumb. I would call it uninformed in the sense of -- not uninformed that physicians are not informed about what needs to be done. But most medicine today is practiced with incomplete records. . You have an incomplete picture of what's happening to the patient. And this can be very, very dangerous. So, for example, if you do not know about a patient allergy and the patient doesn't report it and you prescribe something they're allergic to, the consequences can be disastrous.

  • 13:20:25

    YASNOFFSo, yes, we do need smart medicine but smart means more information. Let me also say it doesn't mean more data. We can't just overwhelm physicians with piles and piles of records, be they paper or electronic. The wonderful thing about electronic records is that we have the ability to organize those records and present them in a way that allow physicians to effectively use them.

  • 13:20:56

    NNAMDII just had a test at a sleep center and they informed me that my physician would be provided with 1,000 pages of information based on this. And I'm, well, who is going to exactly going to read (sic) all these 1,000 pages?

  • 13:21:09

    YASNOFFWell, perhaps if you have a sleep disorder and you read those pages, it might help you...

  • 13:21:16

    FUISZPut you right to bed.

  • 13:21:18

    YASNOFFBut I suspect that your primary care physician is not going to read very many of those pages. But the real issue is will your primary care physician get any of that information and see any of it? And when you see your primary care physician next time, will you instead be asked, what happened at the sleep center?

  • 13:21:45

    NNAMDIThank you very much for that response, but I know I'm being charged for all 1,000 pages. Here is John in Fairfax, Va. John, you're on the air. Go ahead, please.

  • 13:21:56

    JOHNI had a couple of points. One of them being that typically because of the pressures you mentioned earlier, any improvements in efficiency will almost certainly go to increasing throughput and not increasing the care that any physician can give to any patient.

  • 13:22:12

    NNAMDIWhat do you mean by increasing throughput?

  • 13:22:15

    JOHNWell, how many patients can you get through in a day?

  • 13:22:16

    NNAMDIGot you.

  • 13:22:18

    JOHNThe other point is that we've all heard of big data and there are some components of that called signature recognition and exception processing which allow automatic systems to extract and maybe make a short synopsis that the physician can read in the minute or two that they might have before seeing a patient, which will bring out the highlights of both the -- you know, the assailant history of a patient and any problems that the automatic system had flagged. And that can very much increase the effectiveness of short care.

  • 13:23:00

    NNAMDIIt can increase the effectiveness, Nareesa Mohammed-Rajput, but does it also increase the pressure on the physician?

  • 13:23:07

    MOHAMMED-RAJPUTSo I think that it can increase the pressure but it's because it's -- I guess in a way it's a good thing because the ultimate goal is that the provider wants to provide what -- safe care for the patient. And so it's not just throwing volumes of data at the provider. Because throwing volumes of data at the provider without giving them a way to interpret the data that they're getting, to provide the safest possible care for their patient is very challenging.

  • 13:23:36

    MOHAMMED-RAJPUTSo I feel pressure because -- as a provider I feel pressure to take care of my patients because I want to do what's right for them. And I want to provide the safest possible care that I can for them. But it's very challenging for me to go through 1,000 pages of data to come to the three lines that I really need to be able to provide you the safest care possible.

  • 13:23:58

    NNAMDIBilly Yasnoff.

  • 13:23:59

    YASNOFFI wanted to comment on the throughput issue. I think it's important to recognize that up until recently, our health care system has been based on payments for services, so-called fee for services. And of course, if you're being paid for services your financial incentive is to deliver more services as quickly as possible or, as the caller said, increase throughput. But we are in the process of moving from this fee-for-service system to a pay-for-value system where we measure the value that is delivered to patients. And in that kind of a system the incentive is to provide higher quality lower cost care.

  • 13:24:41

    YASNOFFAnd it's interesting -- again I'm going to pick on Kaiser and Ted can answer since he's here -- but one of the advantages that Kaiser has is that their incentive has always been for value because they have a combination -- they are combination health plan and provider. And therefore it's in their interest to provide high quality efficient care. But if you're being paid for every service you deliver, naturally you're going to tend to deliver more services, regardless of what the outcome of those services is.

  • 13:25:17

    NNAMDIYou've been picking on him but he seems to be mostly agreeing with you.

  • 13:25:21

    EYTANYeah, so Kaiser -- we are not paid on throughput at Kaiser Permanente. We are paid for health. So the efficiency that we care about -- and we call our patients members -- the efficiency we care about is the members' efficiency of being healthy. So if they don't need to see the doctor, then we'd rather them be at work and productive. If they need to see us, we're available. So what technology allows us to do is create the space where they can contact us the way they want to. And again, with technology with them handling things that they don't need to see us for, we may actually have more time with them rather than less, and that's more time for work.

  • 13:25:48

    NNAMDIWell, Alice Fuisz, you work at an independent practice, so I'm presuming that you have different incentives, different pressures?

  • 13:25:57

    FUISZI am in a fee-for-service environment still. But what I find is that because I can communicate with my patients in between visits, again mainly by emailing them, that I do have more time with the individual patients when I'm there. And even though I would make more money if I saw more patients in the day, if I increased the throughput as he called it, which is a good term, I find that the fact that I can communicate with people in between visits allows me to spend more time with the patients when they're in front of me to, as Nareesa said, you know, have a good relationship with them and have them have a chance to tell me all their concerns.

  • 13:26:36

    NNAMDIGot to take a short break. If you have called, stay on the line. We'll be back and we will take your calls. If you'd like to call, the number is 800-433-8850. You can send an email though to kojo K-O-J-O @wamu.org or send us a Tweet @kojoshow. Are you able to contact your doctor my email? You can also join the conversation at our website, kojoshow.org. I'm Kojo Nnamdi.

  • 13:28:51

    NNAMDIWelcome back to our conversation on how technology impacts doctor-patient relationships. We're talking with Dr. Alice Fuisz. She's an internal medicine doctor with the Washington Internist Group here in D.C. She's also governor of the American College of Physicians D.C. Chapter. Dr. William Yasnoff is managing partner with National Health Information Infrastructure Advisors. That's a consultancy firm. He's also CEO and president at Health Record Banking Alliance.

  • 13:29:17

    NNAMDIDr. Ted Eytan is director of the Kaiser Permanente Center for Total Health. He's a board certified family physician but today he works with large health systems and technology experts to explore how health IT can be used to engage patients. And Dr. Nareesa Mohammed-Rajput is an internal medicine doctor with Johns Hopkins Health Care. She's also the lead physician coordinating electronic medical records in the Hopkins health care system. We've been inviting your calls at 800-433-8850. I'd like to go to Sara in Herndon, Va. Sara, are you there? Go ahead, please.

  • 13:29:53

    SARAYes. Hi, I'm here. Thank you very much, Kojo. I think that having a productive patient-doctor appointment is the responsibility of both the patient and the doctor. I always come to my appointments with some specific notes about what my issues are, things I need to remind them about. So I think there is patient responsibility. That said, I guess my question comes out of I've had a couple experiences with doctors using electronic records and they've not been great.

  • 13:30:16

    SARAOne doctor clearly didn't have the training and he spent -- a specialist -- almost my entire appointment trying to figure out how to use the system and printing out the screens. Okay, that wasn't great. The other (unintelligible) doctor had a system that they'd had for a number of years. And when I asked for a copy of my records to take to a major medical center, the printout was completely wrong. There were things like a flu I'd been treated for three years ago that showed up as a current problem. And I had the office manager say, well we don't have any way to remove it from the system. It's just -- we can't change it.

  • 13:30:47

    SARASo my question is, are we ultimately improving patient care, because I'm a fan of technology. But when you hear things like you get a record and it's not accurate at all and you have a major medical group that said, well we don't have any ability to change this. It leaves me kind of confused.

  • 13:31:02

    NNAMDIBilly Yasnoff, please help.

  • 13:31:04

    YASNOFFSure. Clearly, first of all, it's good that you ask for a copy of your record. All patients should do this for exactly the reason that you mentioned because it's important for patients to take a look at their records to make sure that what is in them is correct.

  • 13:31:23

    SARARight.

  • 13:31:24

    YASNOFFSo that's really good. All electronic record systems should have the capabilities for amendment. It's general practice in health care that we never erase anything that's recorded. If it's wrong, we cross it out, mark it as an error and then add the corrected information. And electronically we can do the same thing. And it should be done the same way because we want to have -- even if there's incorrect information, we want to be sure that we can trace how that information was used. And we don't want information to just disappear unmarked.

  • 13:32:07

    YASNOFFSo I think you need to be very insistent with the medical practice and you may need to write them a letter for them to actually add to the record, saying that this information is incorrect and you want them to at least indicate in the record that this other information is incorrect.

  • 13:32:28

    NNAMDIThank you very much for your call, Sara. This is a question for each of you. When I think about the classic model for doctor-patient relationships, it seems almost paternalistic. Patients answer questions for the doctor. The doctor listens and then he or she tells you what to do. One of the selling points for these new technologies from a patient perspective seems to be the idea that we can have more of a role in that relationship. Is that happening? First you, Ted Eytan.

  • 13:32:55

    EYTANAbsolutely and that's our goal. So giving -- as Bill says, giving patients access to their own information when they want to get it allows them to ask better questions. And actually when Sara was describing how she prepares her visit, all of us were nodding our heads, smiling saying, those are great patients. So this technology allows patients to be part of the team. It also changes the physician relationship to be accessible and responsible to the patient's request.

  • 13:33:20

    NNAMDIAlice.

  • 13:33:23

    FUISZI'm not sure I have an answer for that.

  • 13:33:27

    NNAMDIAnd Nareesa.

  • 13:33:28

    MOHAMMED-RAJPUTSo one of the things that -- I think that Sara brought up that was really important, is the fact that it's important that the patient see what's in the chart. And so that's part of the reason why I formed a triangle is that the patient can see everything that I see. But the other thing that I thought was important was that we need to make sure that the information that's in the chart is accurate. And that's another reason why I spend the 10 to 15 minutes to try to go over it with the patient, is because I want to make sure that the information is accurate.

  • 13:34:04

    MOHAMMED-RAJPUTAnd the other thing that's -- that I'm applauding Sara for is that she is coming to her office -- her visits prepared. She has specific questions. And so that's also very useful and helpful to focus the visit so that what the patient wants gets addressed.

  • 13:34:24

    NNAMDIWell, oh, yeah, I'm sorry, I forgot Bill Yasnoff.

  • 13:34:28

    YASNOFFI think, Kojo, describing the physician-patient relationship as almost paternalistic is very kind. I think it clearly has been paternalistic, but I think it's...

  • 13:34:41

    NNAMDIHow about dictatorial?

  • 13:34:42

    YASNOFFWell, I'm not sure I want to go that far, but I'm sure that's true in some cases. But I think it's important now -- and I think the way technology allows this to evolve is that a doctor-patient relationship is a collaboration. It's a partnerships. And it's a partnership for health. And what we're learning and what we know is that much of what ails folks, many of the problems that people have are beyond what a physician can help with. Many of those problems stem from behaviors of the patient.

  • 13:35:23

    YASNOFFAnd so the doctor and the patient need to work together in order to maintain and improve health. And so this is a very positive thing. And the more engaged and informed patients are, the more effective they can be in holding up their end of the partnership. After all, as a patient it's your health.

  • 13:35:42

    NNAMDIAlice Fuisz.

  • 13:35:43

    FUISZWhat I would say back to Sara is that when I first started to use an electronic medical record, there were a lot of flaws in the system. And I was frustrated by that. But what I've seen over the years I've used it is ongoing improvements in the systems. And so what I tell my patients when they're frustrated, for example with our patient portal, they have an access code and they might have trouble getting it to work one time and then they have to call and get a new code, is it's better than what we used to have. And that if we don't jump in and try it out and work out the kinks, it's never going to work.

  • 13:36:22

    FUISZAnd so it's an evolution. And the doctor that she was referring to where they said they couldn't fix the record, it might be that they couldn't fix the record. But a year from now they'll have the capacity to do it or they just --they're doctors that are trying to use technology that they're not that familiar with and they need to get some help with it.

  • 13:36:42

    NNAMDIWe got an email from Michelle who says, "My OB-GYN texts with me, which came in handy the morning our baby was born." But we also got an email from Peter in Arlington, Va. and, Alice, I'd like to know when there is just too much communication. But here's what Peter wrote."I would love it if my doctor would communicate with me via email, a technology accepted by most at the end of the last century. This way I could send a list of questions and hopefully get meaningful answers. We could both address my medical issues on our own time. No need to go to an office, park, wait, wait more and get a one-word answer."

  • 13:37:21

    NNAMDII find it a little troubling when Peter says, "we could both address my medical issues on our own time," which seems to suggest that when you are emailing your patients, you're doing this on your own time.

  • 13:37:33

    FUISZCertainly I am. One of the advantages of an electronic record is that I can have it with me wherever I am. And in my case, I finish seeing patients when I'm done and I go home and I may turn on the computer and start to communicate and do all that follow-up with people in the afternoon or the evening. In traditional medicine ten years ago, pretty much every doctor I knew would finish seeing patients at 5 or 6:00 at night and that was it. They closed the doors to the office and they came back to work in the morning. And they didn't do any work at night.

  • 13:38:01

    NNAMDIYeah, but it also suggests to me that I could be sending you ten-page emails every night.

  • 13:38:06

    FUISZAnd what we -- what we do with those patients -- what I do in that situation is I will certainly read the email when I have a chance to read it. But if somebody has a whole list of concerns, I will say, this is too much for me to respond to by email. Let's set up a visit so we can talk. And that email could lead to a phone consult. Certainly I'm sure in the Kaiser model they could do that. But if they have a quick question, it's so much easier to answer by email. But if it's a lengthy list of ten questions, I'd love to get that in advance before the visit so I know what's on their mind.

  • 13:38:41

    NNAMDIWe all know email can also be an incredibly passive aggressive media but, Ted Eytan, what do you say?

  • 13:38:47

    EYTANYeah, I just want to say, the goal of this is health. And so if the patient needs to write ten pages to be healthy and have a great relationship, we would like to get that message. We're getting about 1.3 million email messages securely sent to us every month at Kaiser Permanente. 100 percent of our doctors do it. And this is part of our work now. It's not in person and then other work. This is part of being -- keeping people healthy.

  • 13:39:09

    NNAMDII'm glad you said securely sent to us because that's what I think Rita in Clifton, Va. would like to talk about. Rita, your turn.

  • 13:39:18

    RITA (CALLERIn an era of the hackersphere, it is a question of mine that if the NSA cannot protect their data or the NSA can dig through anyone's data, this is about, as you said a few minutes ago, behavior as much as it is about enzyme numbers. If those behaviors are put into a log and they are hacked into, you've now opened people up to blackmailers, journalists. As Rupert Murdoch's group hacked into phones, why wouldn't they hack into medical records to embarrass people and print and sell news copies?

  • 13:39:58

    RITA (CALLERI have real severe qualms about having this kind of information and taking it home and accessing people's personal medical history on your home computer through email is another red flag to me. I volunteer as a chaplain at a hospital. We're not allowed to say the patients' names out loud in the hallway. This has huge consequences for people that you're putting all this information out there electronically.

  • 13:39:59

    NNAMDIBill Yasnoff, what do you say?

  • 13:40:00

    YASNOFFI agree completely. This information is very sensitive and I think people understand very clearly that when we do things to make medical records more accessible for good purposes, we simultaneously and inevitably make them more accessible for bad purposes. And, therefore, as we do this, we must have a higher level of protection for medical records that are electronic than we've had in the past. The regulations in this regard are actually good in terms of what's known as the HIPAA Security Rule, HIPAA being the Health Insurance Portability and Accountability Act, that requires encryption of medical information when it is transmitted.

  • 13:40:52

    YASNOFFIt requires that it be stored in secure systems. There are many problems with this. Compliance is not perfect, but I would say that this is always a tradeoff, and so we can't turn away from having electronic records because there's a possibility of harm due to security breaches. What we need to do is take advantage of the ability to have electronic records and make sure our security is up to defending against the threats.

  • 13:41:26

    NNAMDINareesa?

  • 13:41:28

    MOHAMMED-RAJPUTI think that the -- at least most -- at the institution that I work at, we do do secure emailing. And so when we communicate with the patients that are not in our office, and we do it electronically, we do it through a portal. And so it's secure on our end. We are not sending it through, like Gmail or a regular email account. We are not encouraged to communicate with patients even with our work email. We do it through the emailing functionality that's available to us in our electronic medical record.

  • 13:42:03

    MOHAMMED-RAJPUTAnd so we communicate with our patients securely from the EMR to their portal account, and so -- that it's not just a regular email. And, in fact, if patients email me with medical issues because they get my email, I do not answer them with my work email. I respond them to the portal. And if they don't want to communicate -- if they don't have access to the portal, I make sure that they have it, but I make sure that I do not communicate with patients about medical information no matter how, you know, sensitive or not sensitive it is.

  • 13:42:35

    MOHAMMED-RAJPUTBut I do not communicate medical information through regular email. I always try to do it securely through the email functionality that exists within my electronic medical record.

  • 13:42:43

    NNAMDIGot to take another short break. If you have called, stay on the line. We'll try to get to your calls. If you're thinking about calling, the number is 800-433-8850. If the lines are busy, shoot us an email at kojo@wamu.org, or send us a tweet @kojoshow. You can also go to our website, kojoshow.org, ask a question or make a comment there. I'm Kojo Nnamdi.

  • 13:44:58

    NNAMDIWelcome back. We're talking about technology and how it impacts the doctor/patient relationship. We're talking with Dr. Nareesa Mohammed-Rajput, internal medicine doctor with Johns Hopkins Healthcare. She's also the lead physician coordinating electronic medical records in the Hopkins Healthcare System. Dr. Alice Fuisz is an internal medicine doctor with the Washington Internist Group here in DC. She is also governor of the American College of Physicians, DC chapter.

  • 13:45:22

    NNAMDIDr. William Yasnoff is managing partner at National Health Information Infrastructure Advisors, a consultancy firm. He's CEO and president at Health Record Banking Alliance. He also has a Ph.D. in computer science. He previously served at senior advisor for National Health Information Infrastructure at the U.S. Department of Health and Human Services. And Dr. Ted Eytan is director of the Kaiser Permanente Center for Total Health. He's a board certified family physician, but today he works with large health systems and technology experts to explore how health IT can be used to engage patients.

  • 13:45:55

    NNAMDIWe got quite a few emails about Kaiser. I'll share a couple of them with you. This first one is from Eileen in Reston, Va. "I've been with Kaiser for 39 years. I've always received excellent care, but the new digital connection has been wonderful. I feel that I have much more connection with my primary care physician, and after some recent serious health issues, I could see that the specialist and my primary care physician were working as a team for me. for your information, I started with the Georgetown Community Health Plant which became Kaiser Georgetown, then Kaiser Permanente, with the same physicians for more than 20 years, but who are now retired." And this...

  • 13:46:31

    EYTANThank you.

  • 13:46:32

    NNAMDI...we got from Sashi. "I've been a Kaiser client since 2007. I elected Kaiser because of the electronic technology adoption and general emphasis on preventive health. However, I also observed the need to train physicians in interpreting data in statistically significant terms. By this I mean that each test result comes with its uncertainty. My experience has been that most of the physicians still interpret data as it was only one data point instead of looking at the cumulative data that has been made available to them. Specifically, it is relevant in cases where the dosage has to changed or not."

  • 13:47:08

    EYTANWell, this is the -- thanks for the compliments. This is the advantage of a health system. So you're not just seeing a -- you are seeing your personal physician, but we are supported by pharmacists, nurses, physical therapists, who are also helping us, and we've matured to such a point in our systems that we have a lot of background systems that are doing a lot of this interpretation on the side invisible, brought to the physician when they see you.

  • 13:47:30

    EYTANSo even though you may be seeing a physician who is talking about a specific lab test result, in their office and in the background, our systems are actually looking for trends and alerting your care team, and that's how we get the great numbers we're getting around prevention.

  • 13:47:44

    NNAMDIGo ahead, please, Bill.

  • 13:47:45

    YASNOFFI'd like to mention that it's very difficult for physicians to even think about a trend of lab test results when each lab result is printed on separate piece of paper and they have to flip through and look at the different pieces of paper and essentially construct the trend in their head. So one of the advantages of electronic records is that physicians can be presented with that kind of trend information so it's easy for them to consider it.

  • 13:48:15

    NNAMDIOn to Reesa (sp?) in Washington DC. Reesa, your turn.

  • 13:48:20

    REESAThank you. I find this extraordinarily distressing. The doctor -- at the beginning of the program there was mention the doctor is going to look at a screen with me for 15 minutes, and that's considered both a long time in good care. When is the doctor going to look not at the screen, not at the papers, when is the doctor going to look at me? No amount of tech can fix the problem of the lack of human attention and human touch to the physical body the doctor's there to know how to treat in the first place.

  • 13:48:51

    NNAMDINareesa.

  • 13:48:53

    MOHAMMED-RAJPUTSo the -- when I was talking about reviewing the chart first, I want to make sure that I look at the information that I have presented to me about the patient, but then I actually do do a physical exam. The patient does not leave my office without me laying hands on them. And so it's a matter of trying to streamline the thought process, and so when a patient does come into see me, that I look at the information -- as much information as I possibly can to be able to make an informed decision that's safe for the patient, and to make sure that I corroborate what I'm thinking from the data that I'm collecting both from the patient and from the record, as well as from physical findings to be able to create this entire decision process.

  • 13:49:34

    MOHAMMED-RAJPUTIt's becoming increasingly challenging to focus my thoughts or to learn how to incorporate multiple different sources of data and to put together the information in a way that I can explain to you what's going on with your health. And so, you know, it's not that I'm not trying to spend time or none of us are trying to not spend time with our patients, but we're also trying to make a lot of complex decisions from as many data points as possible.

  • 13:50:05

    NNAMDIOne of our callers raised the topic of software programs which could assist physicians to narrow diagnoses or perhaps identify patterns that would not otherwise be apparent. I can see how this would be useful, but it does raise some interesting questions about how much you would want to surrender, if you will, to a computer. Is this actually cutting out the doctor in the practice of medicine, Alice?

  • 13:50:27

    FUISZWell, it makes me think about years ago people would refer to the fact that a patient might have read something in the Readers Digest and now they're reading it on the Internet. And what I would say from my own experience is that sometimes patients come in and they have done a lot of -- they've often don a lot of research before the visit and they have ideas about what the diagnosis might be or what tests they might need because they're read it on the Internet. And I'm very open to that because sometimes they will bring up something that I hadn't thought of.

  • 13:50:57

    FUISZAnd if you are a humble enough medical provider, you're willing to hear them out and, you know, you want to know what their -- first of all, you want to know what they're worried about, and so when they show up for a visit, if they don't say to me, I'm actually worried that it's the Flomax that's making my blood pressure low, than I won't necessarily have a chance to address that because I'm not necessarily thinking of that concern.

  • 13:51:20

    FUISZAnd so I think, you know, the more data that we have from the patient about what they're concerned about and what they've read about and what they want to make sure we rule out, the better off we are in terms of meeting their expectations and answering their questions.

  • 13:51:34

    NNAMDIBill Yasnoff?

  • 13:51:36

    YASNOFFWhat we're talking about here is known as decision support. So the use of computer algorithms to help physicians think about and perhaps respond to patient problems. And I think there's not much to worry about in terms of decision support replacing physicians any time soon. I think most physicians welcome any suggestions that come from software that has analyzed what's going on, and I think the best way to think about it by analogy are the instruments and warning lights in an airplane cockpit.

  • 13:52:14

    YASNOFFNo one would want a pilot to be flying the plane without warning indicators that would go off if something went wrong, and it has nothing to do with the fact that the pilot doesn't know how to fly the plane. Typically in healthcare, our instrument panel has been pretty much blank and has no warning lights. And so with electronic records we can fix that problem and it's positive.

  • 13:52:39

    NNAMDIGo ahead, please, Ted.

  • 13:52:40

    EYTANYeah. I'd like to add to both those points, and I think everyone is kind of believing the same thing here. We're very optimistic about the future, and the way that, especially at Kaiser Permanente, we're deploying technology, and I think the same way you are as well, is to get us closer to patients, not farther away. So we can connect with them in ways we couldn't. We can share information with them in ways we couldn't, and whenever we -- we're constantly testing new technology. And if we find something that gets in the way, we don't deploy it. And actually, we're known really well in the industry for being that way.

  • 13:53:09

    NNAMDII guess as it stands right now, most Americans only have contact with their doctors when they're sick or when they have a yearly check up, but a lot of the things that end up affecting our healthcare are cumulative. Things like our diet choices. One thing new technology could potentially create is a way for doctors to address these cumulative lifestyle questions, right?

  • 13:53:30

    EYTANI'd love to address that. Coming from the -- I work at the Center for Total Health in Downtown Washington DC, and people are welcome to come and visit it. It's a high tech space devoted to talking about health, and we look at exactly those things. So what we're understanding, in a place where we are using technology to achieve unheard of preventive rates, and just as an example, the blood pressure control rate in the United States on average is about 46 percent. In mid-Atlantic states it's 80 percent, which is almost unheard of, and that's what you get with technology.

  • 13:53:57

    EYTANBut when you get there, then you have to look at how did they get high blood pressure in the first place, so it's food, water, the environment. And we're having a lot of those discussions at Kaiser Permanente, and our doctors are actively engaged in some of those issues.

  • 13:54:10

    NNAMDINareesa, most of our thinking about healthcare reform of late has been focused on getting more people covered by the insurance system or Medicaid, but another huge challenge lies in the not-so-distant future, and that is finding enough primary care doctors to serve all of these newly insured patients. Can you talk a little bit about the pressures on the primary care system?

  • 13:54:30

    MOHAMMED-RAJPUTSo -- thank you for addressing that. So that is a known issue is that primary care as a profession is -- it's increasingly difficult to recruit providers to be primary care providers. It is -- we're sort of, you know, the people that are frontline. When patients are sick, we are told to go to our primary care doctors. We'll, we're -- it's difficult for -- to recruit primary care doctors. I'm sure Kaiser Permanente is having this issue. I'm sure that private practitioners are having this issue.

  • 13:55:03

    MOHAMMED-RAJPUTI know that at Johns Hopkins Medicine we are also looking -- constantly looking for people that are going into primary care medicine that are interested in practicing medicine in primary care. It's been very challenging across the nation. Part of the reason is because the physician compensation is not as high as it is for a subspecialty. Part of it is because of the number of things that are on the shoulders of primary care physicians. And so when a patient goes to their doctor, they're going to the doctor, and as a primary care doctor, I'm not exactly sure what they're walking in the door with.

  • 13:55:38

    MOHAMMED-RAJPUTIt could be anything. It could be absolutely anything. And -- as opposed to a specialist who when you walk in the door to see the specialist, they know that it has to do with one specific body part, the lungs, or the heart, or the kidney. But a primary care doctor sees all of that. And so it's very challenging to be a primary care doctor. It's very exciting, it's very rewarding, but it's also very challenging trying to manage and think as broadly as you possibly can to make that first decision when the patient comes in the door.

  • 13:56:15

    MOHAMMED-RAJPUTI think that in the future, because it's been so challenging historically to recruit people to primary care, that in the future it may be more challenging for patients as they become insured to find primary care providers. And so we may have to rely on physician extenders.

  • 13:56:31

    NNAMDIWe're running out of time, but Alice, it's my understanding you can't afford to take new patients with certain healthcare coverage.

  • 13:56:39

    FUISZThat's right. I mean, basically what's happened is, the reimbursements from insurances have remained flat for many, many years, at least in the DC area. And so for a lot of doctors practicing at least downtown in DC, it's hard to participate with the insurances so we end up having a, you know, out of network relationship with those patients.

  • 13:57:02

    NNAMDII'm afraid that's all the time we have. Dr. Alice Fuisz is an internal medicine doctor with the Washington Internist Group in DC. She is also governor of the American College of Physicians, DC chapter. Dr. Nareesa Mohammed-Rajput is an internal medicine doctor with Johns Hopkins Healthcare. She's also the lead physician coordinating electronic medical records in the Hopkins Healthcare System.

  • 13:57:21

    NNAMDIDr. William Yasnoff is managing partner at National Health Information Infrastructure Advisors, a consultancy firm. He's also CEO and president at Health Record Banking Alliance. And Dr. Ted Eytan is director of the Kaiser Permanente Center for Total Health. He's a board certified family physician. Today he works with large health systems and technology experts to explore how health IT can be used to engage patients. Thank you all for joining us.

  • 13:57:46

    MOHAMMED-RAJPUTThank you very much, Kojo.

  • 13:57:46

    FUISZThanks for having us.

  • 13:57:48

    EYTANThanks.

  • 13:57:48

    NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.

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