Over the last year I have been working one day per week in a busy walk-in clinic in which all physicians and staff use an EMR. As with any EMR-based practice, there are ongoing challenges associated with using technology effectively in a clinical setting. Some features of the EMR work well and others are mediocre. Working in the clinic serves a number of purposes. It allows me to keep up with current clinical practices and maintain my skills. It is also a useful reality check in terms of care delivery in an urban primary care centre irrespective of technology.
The intent of this article is not to examine the use of the EMR system in the clinic, but rather to provide my observations regarding use of the primary healthcare system by patients:
- There are a lot of patients who cannot find a family doctor. During every clinic shift I am asked by at least five patients whether I am accepting new patients. Working a single shift per week, I am not able to provide the type of comprehensive primary care and continuity this demands, so I decline. It is nationally estimated that five million Canadians cannot find a family doctor. This number feels realistic.
- Availability wins over quality 9 times out of 10. The number of patients who attend a multitude of walk-in clinics for their day-to-day care is astounding and has serious negative implications for the healthcare system. Even though many BC patients may identify one individual as their “family doctor”, they often see many other physicians in walk-in clinics for a variety of clinical problems including medication renewals, minor medical conditions, sensitive issues such as sexually transmitted infections, and — in some cases — for all of their medical care. Thus, the “family doctor” becomes the repository for reports, lab results, and specialist consults they had not ordered but are cc’d. This situation creates an increasing disjointed way to provide care. In a world of EMRs, it is not possible to provide a comprehensive summary of a patient’s medical care, as the information exists in multiple charts across multiple practices. Without the ability to link patients to providers (through accurate patient and provider registries), it is not possible to create the one-to-one relationship needed for successful use of patient portals and personal health records. The core information is generally incomplete.
- There is no accountability on the side of patients for over-use of the healthcare system. On numerous occasions, I have seen patients during my clinic shifts who have seen one or more primary care physicians for the same problem on the same day because they ‘did not like/trust’ the recommedations of the other physician(s). Not only is this a terrible waste of scarce healthcare resources, it also creates an administrative challenge for the practices. The first practice to submit a claim for the visit to the provincial payment agency (MSP) gets paid and the other claims submitted are rejected. While it is possible to request payment in situations that a patient has been doctor shopping, the process takes place after the fact and requires additional effort and explanation in order to get paid for providing a requested service.
- Some very sick people are receiving their primary care at walk-in clinics. I also find the severity of illness surprising for a number of patients. I have diagnosed patients with spontaneous pnemothorax, pulmonary emboli, and muscular dystrophy to mention a few conditions that I can recently recall. These individuals should be receiving their care in a setting that provides greater continuity. They are also difficult diagnoses to make, particularly in settings where the physician may be seeing a patient for the first time. An EMR helps if a historical record exists for that patient.
Bottom line — we can implement EMRs and a wide range of information technologies in medical practices, but there are policy, utilization, and access issues that are fundamental in an efficiently functioning healthcare system. These issues (and I have listed just a small number) are barriers to effective use of health IT. While it may not be possible to “fix” the broken system, there appears to be a lack of recognition that these problems exist. We have to do a deep dive into the problems, optimize the delivery of care, and then apply technology to these improved business processes.
The alternative, as Bill Gates once stated, is as follows:
“The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.”