Extended Interview: Dr. William Davis
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SUSAN DENTZER: When Cerner [Corp.] came knocking, looking for a community hospital and a community to test out its personal health records product, what was your response?
DR. WILLIAM DAVIS: I thought it was amazing. I thought this was a great idea. … Here was an opportunity for patients to have their own electronic record, and be able to interact with their physicians by sending messages about questions they might have or a request for, prescription refills or, request for visits.
SUSAN DENTZER: And when Cerner actually introduced that technology, initially at any rate, it turned out to be a little bit of a dud. Let’s talk about why.
DR. DAVIS: I think the vision of personal health records was something that the patient would put their own information in so they would get on and they’d enter their problem list and enter their surgeries and enter their medications and take their blood pressure and put it in there. And, it turned out that very few people wanted to take the time to do that. A few people would, but most people were not anxious to spend that much time trying to do it. What they really wanted was access to the records they already had which was access to the doctor’s office records.
So Cerner stepped back and said, OK, we’ve got to redo this whole thing, so they completely rewrote the software and integrated it with the health record, the electronic health records so that patients would actually be able to look into their record and see the things that the doctor recorded. So they could see the list of allergies and immunizations and procedures they’d had and medications they take.
SUSAN DENTZER: And meanwhile, the providers in the community, the hospital, the physicians, the clinics, realized that they needed to be part of this action also, correct?
DR. DAVIS: We had to have training sessions for the physicians because in the early stage the doctor also had to log onto this separate site and look at the patient’s record in order to be able to, to see what they had put in. And to see if they had a message. So if a patient wanted to message me, I would have to go and look at this site and see if there were any messages for me. Well you can imagine when this starts out there are very few people and divided among all the doctors, after two, three, four weeks of going on there, there’s nothing for me, I’d forget about it. I’m not going there anymore.
So as we were training the doctors, they said, you know, this isn’t fair. The patients are getting an electronic health record but we don’t have one. And so we began then the journey of trying to decide on an electronic health record and implement it here.
SUSAN DENTZER: What was the initial physician attitude on average about electronic health records?
DR. DAVIS: Most of them are very enthusiastic about it. I mean there are always people who are worried about, mostly it was about around the issues of security and privacy. But again there were, you know there were probably a third of the medical staff who had never used a computer. Didn’t know how to turn one on, didn’t know what a mouse was, so for them it was quite a challenge to say OK, you have to learn how to use the computer to be able to find the results that you want on your patients.
But, you know, they didn’t, they didn’t quit, leave or anything, they just, it took them time to learn that and, and so there was, I’m sure there was a lot of anxiety and doctors are you know, they like to believe that they are really in charge of everything so to admit that there was something they didn’t really know anything about, you know they got their kids to come over and show them how, how the computer works and so by the time we were ready to start training on the use of the system, most of them were, were up to speed.
Security and privacy concerns
SUSAN DENTZER: Now you mentioned there were concerns about security and privacy. Tick off for me a list of the top worries that people had.
DR. DAVIS: The main thing is that people see constant reports of break-ins on, on record systems and stolen financial data and social security records and so they'd think about you know what's going to prevent that happening with my medical records. And interestingly enough, patients are less worried about that than their doctors are, but it was, it was certainly a concern and then there's also from a physician standpoint, we have our own patients, people who come to see us all the time, and rarely ever see anybody and so we, we begin to imagine that, that nobody else should be able to look at those records and of course that's not true.
I mean our partners are always going to have access to those and depending on the group that you're in, that'll depend. So there's a little bit of concern initially about I don't want everybody looking at these records that they produce. But I think they recognize that it was much better for the patient to have a shared record, shared by everybody in the community so all the physicians and the hospital than to have you know separate silos of information.
SUSAN DENTZER: Were people forgetting that, after all, it's the patient's record, not the doctor's record?
DR. DAVIS: Sure. And you know when you say to them, they just walk in and sign a piece of paper and by law we have to give them the record. We have to copy it and hand it to them. That's you know it really is theirs. The paper form that we have is ours, but all the information is theirs, so if they want it, we have to give it to them.
SUSAN DENTZER: Now as the system was implemented, there were also some bumps along the road. What were some of those bumps?
DR. DAVIS: Anytime you adopt a new system you change work flow and so people have to change, to some degree change the way in which they do things. So it takes a little bit of adjustment there. If I am used to looking at a paper chart and finding information that I know approximately where I'm going to look at that and now I have to go to a computer and find it a different way. You know in the days when we had paper charts, typically the paper chart would be in the door outside of the patient's room. Well now when you walk up to the door there's nothing there. Except maybe a folder with their name on it so you know who's in the room.
So you, you didn't have the chance of sort of taking that paper record and thinking through it before you went in to see the patient. So you either have to carry a tablet with you so you can look up their stuff, or you've got to go to a computer and look it up before you go in. Now some people we know, we see them so often we don't need to do that. But a lot of patients you know if you haven't seen them for 6 months or a year, you won't remember what medicines they're on or what kind of problems they have. And you know I'd feel much better if I know a little bit about the patient before I walk in the room, so I won't be too surprised.
Value to the physician
SUSAN DENTZER: And you said that a real issue physicians obviously have is with memory and remembering patients and that these systems are very helpful.
DR. DAVIS: Yes, when you have a paper based system, you are relying on your memory to a large extent about the patient. Now the paper records can have various kinds of ticklers. They can have a problem list and medication list. Somebody has to keep those up to date, and they usually are not, in a paper system. So you know it's very easy to not know the stuff that you should know about the patient when you're seeing them. It's much easier with an electronic system to find them, because it's all right there and it should be current.
SUSAN DENTZER: So these systems are kind of a backstop memory.
DR. DAVIS: Right. Dr. Larry Reed who was the father of the problem oriented medical record, used to give talks and he'd say: how many causes of hypercalcemia are there? And most physicians can maybe think of seven, some of us maybe only three or four. There are 60 plus. So if you have a patient with an elevated calcium level, how do you decide what's wrong with them when 60 of the diagnoses we'll never even think of? So you know they won't ever come to mind. So you know that, that's where the computer's wonderful. You can say to the computer give me the, the reasons for hypercalcemia and it'll show you, all 67 of them. You can say, now most of those don't fit, but here's a few that are true, I forgot.
Or his probably more famous example is the airplane pilot and copilot getting ready to take off and they say, what the heck, let's just take this check sheet and we'll forget about it. Let's see if we can remember all the things we need to do before this plane takes off.
SUSAN DENTZER: You wouldn't want to fly with that guy.
DR. DAVIS: I don't think so.
SUSAN DENTZER: What about the system do you personally feel is the biggest value to you as a physician?
DR. DAVIS: Access to the record any time any place. I mean that's just a huge advantage. Before the electronic records, we'd get a request to call a patient and we'd say well I need the chart. And in many offices it could take several days to find a paper chart and some we'll never find. Ten percent of the paper records are never found. So you have this huge delay in time. I can sit down, bring up the patient name, click on it. I have all their information, whether I'm here or at home, traveling, so that's just a huge, huge advantage. Now being able to, to order medications online and some of these other things is certainly a big advantage, but I think that, that access is just an enormous advantage.
SUSAN DENTZER: Do you believe you have more time with patients now as a consequence of having a lot of the automated features of the system?
DR. DAVIS: Yes. It changes how you use your time. So if you have 15 minutes per visit, and you spend the first 9 minutes just collecting information from them, before you do anything else, you know half of your visit is gone already. So if you have an automated system that has most of that and, and in some cases I actually have patients complete questionnaires before they come in, so I'd gotten most of the information I need to ask about, already recorded, instead of having 9 minutes I can take 3 minutes to review all this information. I've got all that extra time to use for talking with them about their problem, patient education, examination, whatever you need to do. So it changes how you use your time. It doesn't, I don't know that it creates time for us, but...
Diagnosis by e-visit
SUSAN DENTZER: And what about the issue of getting email questions from patients or e-visits? Some doctors have rejected that out of a sense that you really can't know much about a patient until you see a patient right in front of you. How do you feel?
DR. DAVIS: I understand that concern and I think to some degree that's true. There are problems for which the history is the only thing you need. Now people argue with me and they'll say if you, if you are a depressed patient, and I can ask you questions, I can do that on the phone, I can do it on the computer and I can tell that you're depressed. Now I can also tell that you're depressed by looking at you. You know and you're disheveled and sad looking and kind of sit there. I mean that, that's certainly additional feedback but I don't need that in order to make the diagnosis. Or if you call up and say I'm going all the time to the bathroom, I don't need any more information. I already know what's wrong.
So a lot of those kinds of things you can do with an e-visit. But some things you can't. And you just have to say I need to see you. See what's going on. Do the tests. If you're having chest pain, and shortness of breath and sweating, I need to see you. This is not something I'm going to, you know with, with an email or an e-visit.
SUSAN DENTZER: And you also do your e-prescribing as do others on the system. What is the value of that?
DR. DAVIS: It's certainly convenient. I don't have to write out the prescriptions. It's certainly safer because we don't have the legibility issues that we often see where the doctor's handwriting is atrocious and the pharmacist guesses and gives him the wrong medication. And it creates a current medication list for you. You know if I'm just handwriting prescription and giving them to people, and then I look at their record, those medicines may or may not be recorded. In the paper world, it would require me to either dictate or write in what I give the patient. Now I don't have to, once I send it, it's part of their medication list.
DR. DAVIS: So you have a much more accurate and current medication list if it's used. You see that in (inaudible) institution as a problem because we have not yet convinced our psychiatrist to use the electronic prescribing. So we have patients who come in and they may be on three or four psychiatric medicines. We have no idea. Now hopefully the patient will tell us. Or hopefully we'll remember to ask. But a lot of times they don't know what, what it is. Well I have these two that I take in the morning. They're blue and I have two more that I take at night. Yet we don't know what that is. Well now if I'm prescribing, are those drugs going to interact with what the patient's on from the psychiatrist? Maybe. I mean it's just hard to know and so if you, if you don't have an accurate medication list, you have problems.
SUSAN DENTZER: These are psychiatrists in the community who won't do this? Why?
DR. DAVIS: That's a good question. We keep asking them that. I think it's habit. It may be a matter of convenience for them in terms of how they you know the, our visits are kind of centered around some ways, to some extent on the computer. You sort of have this triangle with the computer, the patient and me, and so we're using that information, follow through the visit, looking after medications, looking up their last visit notes, but psychiatrists tend, to you know they sit and talk with the patient and they, they don't, they're not focused around using the computer for anything. So they just stop at the end and say okay now I've got to do these prescriptions for you. It's been hard, hard for them to do. They're used to pulling out their pad and writing down things. But we're working on it.
SUSAN DENTZER: There still are some limitations from your perspective. What needs to be improved?
DR. DAVIS: In our own office what we did was to write a query that we run on the computer to get back reports that we use to track down patients. But it would be much nicer to be able to just sit down and have the reports already there. So you could say give me my diabetic patients, by provider, by clinic, and you'd get a list and you could see precisely when they had their last tests. If they're overdue it's red. If it's coming up due, it's yellow. That functionality is available but we haven't implemented it yet. Another thing in the hospital is what's called meds reconciliation where as the patient comes, say from the community, Â into the hospital, they have a list of their medicines. Which one of those are you going to continue? Which ones are you going to wait or discontinue?
And JCAHO [the Joint Commission on Accreditation of Healthcare Organizations] actually requires that that be done. And in a computer environment you should be able to see that and just say, okay, bring those into the hospital. These I'm going to put on hold until the patient goes home, or these I'll discontinue. And then the same thing when the patient's ready to go home, you've got a list of medications, now you're going to restart the prescriptions. So that kind of functionality is not yet available, but will be hopefully by the end of the year.
SUSAN DENTZER: But the bottom line seems to be that nobody wants to go back to what existed before. If anything they're impatient that the system can't do even more for them now. Is that fair?
DR. DAVIS: Absolutely. Early on we had some problems with time delay for information to appear. So you'd click on something and it would take 30 seconds for the computer to bring up the information. And you know that just really upset people. They had to wait. They're sitting there and waiting for this to appear and I said, well, you know what was it like before the computer? How many minutes do you think it took to go find that chart if you could find it at all and use it? But they don't think that way and then they're thinking now, "Well I've lost 30 seconds here. I wanted it to be 3 seconds," and they're right. It should be. But when you say, well would you like to go back to paper? Nobody wants to do that.
SUSAN DENTZER: Why do you think so few patients relatively speaking are using the personal health record?
DR. DAVIS: For many people it's a technology challenge. It's not something they're used to. I think they're getting more used to it as they use EBay and order things online, they're getting more familiar with that. I think it's probably largely because we haven't done a very good job of promoting that. You know if every patient came in and I said to them, "You need to use this and here's how you sign up and I'm going to walk out and make sure you did that," I'm sure we'd get more participation. But it's just enough of a challenge that for some people they're not quite ready to try that. And I think a lot of them just don't know about it. We haven't told them.
Nationwide use of electronic record
SUSAN DENTZER: As you know President Bush called for nationwide electronic health records by 2014. Many of the Presidential candidates want to push that along even faster. What do you think about the likelihood that the nation will have nationwide access, not a single system obviously, but nationwide use of electronic health records on that timetable?
DR. DAVIS: I think it's pretty high. When you think about health systems, big groups, they're buying into that and implementing it in increasing numbers and of course they have a big piece of the healthcare population. I think the challenge is going to be more in the small clinics, the single doctor and two-doctor groups that still provide a lot of the medical care in an ambulatory basis. For most doctors it's been the cost and I think many of the vendors have begun to see that they've got to make this cheaper. It can't be expensive because people can't justify that. Now if you've got some sort of government incentive, that might help.
If you look at England, 90% of their doctors, their offices have had electronic records for 20 years. And the reason for that was the government paid for them. They said, you should have electronic records and you can choose whichever one you want, but we'll pay for it. And the result is that they, they've had an electronic record system there for several decades now.
SUSAN DENTZER: But you think that if they're going to reward off financial incentives for doctors, we might get there faster.
SUSAN DENTZER: People have observed that the U.S. healthcare system is probably the most backward large industry in the country in terms of its use of information technology. Do you agree?
DR. DAVIS: Absolutely. I'm sure that 15 to 20% of the doctors in office practices are using electronic health records. So 80% of the physicians in offices don't have electronic records at this point. There's a big gap there.
SUSAN DENTZER: Should we be outraged as citizens that there isn't more like 100% use of electronic health records in the physician corps, or 100% in the hospital setting?
DR. DAVIS: Absolutely. How many people, how many of us want to get on an airplane where you know only, only 20% of the pilots use the checklist? Why would you do that? I think we should be outraged because the technology is there, it's totally available. We're just not using it yet.
SUSAN DENTZER: And if you were giving a word of advice to physicians who might be on the fence about this in the next year or so, what would you say?
DR. DAVIS: It's time to change. It's time to do it.