Solving Problems with Clinical Data
This week I am talking to Richard Schreiber, MD, FACP, Associated CMIO at Penn State Health Holy Spirit Medical Center at Penn State Health. Dick is a professor in Internal medicine, a career choice made in his 4th year of medical school as he was looking to solve the mystery of Diagnosis, long before this because a household activity thanks to the medical series ‘House’. As you will hear he was always asking for more data as he sought a better way of treating disease and delivering healthcare.
He describes himself as the squeaky wheel in healthcare that has led him to a long career in Medical Informatics with an initial focus on the display of data, specifically laboratory information and has continued with multiple Electronic Medical Record implementations. He details the many positive aspects to the EMR that includes the fact we are no longer searching for the medical record but requires any user to become familiar with the tool to derive the maximum value. He also notes that EMR’s are Incremental offering users the opportunity to build their notes in small stages and to add elements form other areas of the health system before they are published.
The downsides are well documented with some difficult usability challenges but not all problems are a function of the EMR but driven by the regulatory requirements that drive the note bloat we are all frustrated with.
Healthcare Needs More Systemness
Listen in to hear his vision and dream for Medical informatics that sees all the clinical content created as a natural by-product of the interaction taking place between the clinicians an the patient (a concept I covered in ‘Capture the Story’) and hear his career guidance for future entrants to the world of medicine that is now deeply imbued with technology – something he describes as a need for ‘Systemness’
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
And today, I’m delighted to be joined by Dr. Richard Schreiber. He is the Associate CMO of Penn State Health tech. Thanks for joining me today.
Dick Schreiber
And thank you so much for the invitation. I’m, it’s my pleasure.
Nick van Terheyden
So as I do with all my guests, I think it’s always important to get a little bit of background history, you’re a physician, but not your average physician, if anybody ever is tell us a little bit about your background and how you got to where you are.
Dick Schreiber
Yeah, I’m one of those people that always knew that he or she wanted to be a physician. In fact, I started wanting to be a veterinarian, but that’s another story. But when I got into medicine, I was enthralled mostly by internal medicine, the the challenges, the difficulties, and the all the different aspects of difficult diagnoses, lots of laboratory information, all of that. So that evolved over time, not only as a, that I was an internist. But I also became the squeaky wheel known as the squeaky wheel at my various institutions, meaning, I always needed more data, I always needed more information at my fingertips, I was the kind of person that always thought there was a better way. And when you’re dealing with paper, and slips of paper and handwriting that I can’t read, including my own, I naturally fell into what now we know, is the field of informatics. And my first foray was into laboratory display. And I’ve been doing that ever since. In fact, I had my most recent meeting about laboratory display about an hour ago. So it’s still something that I’m working on. I was in full time, internal medicine practice doing office practice, hospital work, nursing homes, rehabilitations home visits, the whole bit in primary care, and also secondary care. And I slowly evolved into the position of what I later termed to be the chief medical informatics officer at my local hospital that I joined. Details aren’t important. But over time, my the institution where I primarily work, FIRST WORKED WITH ONE on his own privately, and we put in a electronic record and that was quite successful, then we were bought by a larger institution. And I don’t know, Nick, if I should be naming individual institutions. But if I can, I would. Well, Holy Spirit was bought by by geislinger. And more recently, in November, this past year 2020. We were sold and bought by Penn State. So now I am the Associate cmo for the Penn State Health System. And my primary locus of action is at Holy Spirit, the hospital that I’ve worked in since 1984. That’s my informatics story and something of a nutshell.
Nick van Terheyden
So that’s great. First of all, I want to call out the fact that you were interested in internal medicine before house, the TV series was the name because it sounds to me that’s like, that was the trigger for you. Right? That was the mystery of diagnosis. Is that? Is that a fair assessment?
Dick Schreiber
It is. I was toying between ophthalmology and internal medicine during my early fourth year of medical school, ophthalmology because I could do things a surgery. My brother became a surgeon, my, my father was a surgeon. So I thought I would be in one of the doing arts as it were. But as I remember this very clearly, I was looking at the fundus of a woman with sarcoidosis. And it was fascinating. It’s interesting. We were trying to help her out. I’m a fourth year student, so I wasn’t doing much. But I looked at that. And I said, Well, that’s really important. And this woman is getting good off the illogical care. But what about the rest of the body that’s affected by sarcoidosis? And that’s when I said, Okay, this ophthalmology stuff is fun, but I think I want to do the internal medicine. So that was the intellectual point at which I wanted to take care of the whole patient. And the bigger problem.
Nick van Terheyden
I love it. I it’s fascinating how those inflection points sort of direct you in a very specific sort of career direction. The squeaky wheel I think, you know, data and the need for more information to make decisions. We’ve seen that increase over time in healthcare, you know, there’s no question we’ve moved from this paper base record, which, you know, historically would be these four by six cards that you know, your family practitioner would record your whole history for your whole life on at one point, we’ve now expanded that and you, you run through the different organizations, but one of the things that really stood out about you and is you’ve interacted with many of the different EMRs right You’ve had experiences. So you’re, you’ve seen it all? Can you share a little bit of the good experiences as well as the things that you’ve learned along the way?
Dick Schreiber
Let’s start with the good experiences. Once you can become fast file with an electronic record, it’s just like any other tool. I mean, I’m not going to compare myself to a surgeon. But surgeons know this inherently, when they learn an operation, say an open Colossus ectomy. Well, then they learned how to do laparoscopic cholecystectomy is new instrumentation, new tools, new techniques, and they adapted to it and became expert at it. Well, of course, the EHR is not as elegant as a laparoscope. But my point is that everybody in medicine can use the EHR as a tool to get what he or she needs, in order to take care of patients. And, you know, we might have thought of it as a typewriter before or a PACs to be able to see our x rays right away while we’re still with the patient and show them the X ray, that sort of thing. So each new feature of an EHR, whatever it may be, is another tool in our toolbox as to how do we take care of patients. So access, unbelievable access, I mean, the days of my routing in the hospital and not even be able to find the chart. I mean, anybody that neglects that as a feature, certainly has forgotten what working on paper was all about. It was horrible. Then I had zero information. And nobody knew where that chart was, I couldn’t even document if I went to see the patient, if I knew them well enough that I could just go in and delete, see the patient, talk to them. Tell them I’d be back later, when I finally found the chart. I mean, that was agonizing. And patients lost trust in us when we did not have the information that we had. Now, there’s essentially short of, you know, an electric storm and you know, no power whatsoever, we have instant access anywhere, anytime, even if someone else is using the chart at the same time. So access is clearly
one of the
Dick Schreiber
top highlights of electronic records. So is access to the information, I can find anything that’s in there, if I’m good enough, that also the mirror image of that is if you’re not so savvy at using electronic record is finding all the information because now there is a ton of information. The proverbial you know, drinking from a firehose, and the electronic record is much like that. I can do things intermittently, I can write a temporary note, which I’m not intending for everyone to see it because I have further things I want to do before I publish the note. While your viewers couldn’t see what I just did, but I put publishing quotes there. your listeners, excuse me, but what I’m getting at is, I can do incremental work. And you can’t do that really in paper unless you go back and forth. And that’s a nuisance to communication with other clinicians. If there was such a thing as good interoperability, I can send my records on a patient, you know, across the country to San Francisco in a in an instant. Well, that’s coming to be a reality. It certainly is better than it used to be. But it’s not where we need to be yet completely, but it’s better than it has been. I could go on. So that’s mostly the positives, the downsides, usability, you know, I think anybody that’s ever used an electronic record or watch their doctor, try to use one, even if you’re a lay person understands that these are not necessarily usable. I always like to distinguish, however, different aspects of usability because many people blame the EHR for long notes, copy paste, repetitiveness in the chart, inability to find things. You know what a lot of that’s regulatory, and a lot of it just isn’t necessary. Now, CMS is trying to decrease the burden, at least on ambulatory practices, so you don’t have to document quite as much as you used to, as of January 1 this year, but we’re nowhere close to what we really need to be. Your notion of the four by six index cards reminds me that when I first went into practice, as an internist, there were a couple of retiring family practitioners in the area, and they would send me their patients. One of them indeed, kept his notes on three by five index cards. And then sometime in the late 50s, changed to four by sixes. The entire record on say, a 60 year old person that he’d been taking care of, since he gave birth to them was maybe an inch or two thick of index cards, because what he was documenting was only the essentials. So if there was a note from, you know, January of 1966, that said, St. tamp 104 lymph nodes and large two plus pharyngitis three plus extra day positive strep Rx, pcn v k 500 q ID five times 10 days. One line tight. I know exactly what he was looking at. Now, for any of your listeners that didn’t that aren’t medically inclined, I’m describing someone who has strep throat. And you don’t have to have five paragraphs, including the family history, unless it’s pertinent like to other people in the household or sick. What I’m saying is, records are more concise back then they are not any more. Why are they not concise? Mostly regulatory. That’s not the hrs fault. So there are downsides. But we have to be careful when we place blame.
Nick van Terheyden
You know, I I think that’s important. First of all, I love that you cite the EMR as an incremental toolset, hadn’t thought about it in that way. But you’re right, you can sort of keep this private, whereas that wasn’t possible with the medical note, unless you were sort of inserting sheets of paper. I mean, I think great point, because that’s the way that we think through medicine. But you’re right. It’s not a technology issue. It is this regulatory, and I want to say mostly billing associated, that demands that all of these things are included to prove you’ve done something. And, you know, I’ve got this constant phrase ringing in the back of my head, as we’re talking through this. If it isn’t documented, you didn’t do it was what we were, you know, instructed, is that part of the challenge is that something that we should be trying to change can change even I mean, it seems like it’s inextricably linked with the EMR at this point.
Dick Schreiber
It is, but I think you’re making or I’m going to say you’re making two points here. Your second point about linking and, and so on is one thing. The first was the incremental ism. And, being that that’s an important theme for you. You know, on a paper chart, we had the documentation, we had patient complaints, we had laboratory tests, and x ray reports, but no images, just as an example, now we have linkages to the actual image, we have a link to the patient portal, which has not just the information that the patient phoned in for refill on their prescription, but the questions they were asking, and it’s in real time. So the EHR incorporates new functionalities along the way that we never had before, which is a good thing. And now I can look up, you know, in certain vendor products, at least, I can look up their medical records from Indiana, you know, when the patient was hospitalized out there, which I could only get as a copy, or faxed and then incorporate into my paper chart as an agenda, you know, but now I can look at it in virtually real time.
And your second point is, Can we do something about this? And the answer is, Yes, we can. Right now, if I say, I discussed this with the patient. That doesn’t suffice. It documents that I did something. And in the absence of documenting something, then I never talked to the patient, according to the lawyers. But if I say I discussed this with the patient, that’s not going to be substantial, substantial enough. I have to say, what I discussed and what questions I answered, and what questions the person actually asked me. So we are we are plagued with this enormity of documentation that really hides the patient story, in my opinion. There are some people over my years of experience, who can somehow bring an entire patient story into sharp focus in a page I I admire that I can, I can’t do that. Some people say I sometimes can do that. But it’s usually when I’m dictating a note, and I just reiterate that the whole story that I heard, but some people can really hone it in, in a few sentences, and you really get the idea of what was discussed, between patient and doctor. But I think we are incredibly burdened with with regulations, and what the insurance companies and the lawyers and so on expect of us that it really gets in the way of our practice, I think it’s going to need to be a conjoint effort. And one of the things that I’ve written about before, in calling to informaticists is really we have to stand up for our patients so that our notations, our documentation, and the EHR really reflects the interaction between doctor and patient, and not justifying how we deal or how much time we spent, or the complexity of care. Most medical care is complex to begin with, how can I distinguish between moderately complex and very complex? I mean, really, come on.
Nick van Terheyden
For those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Dr. Richard Schreiber. He’s the associate cmo for Penn State Health, we were just talking about the evolution of EMR and the challenge of satisfying regulatory requirements. And that overhead that essentially commits us to putting in information that, I guess, in my mind doesn’t contribute to the clinical course, really, it’s serves a billing purpose, but that’s really a separate activity. And part of me thinks that the EMR came from that heritage, which is why we have the model that we have versus coming from a clinical end is that I mean, you know, as I think about the VA system, which didn’t have so much of that billing aspect, perhaps that was a better clinically orientated system, if you’ve got any familiarity with that.
Dick Schreiber
I don’t have any personal experience using their current system than he is current system. But I’ve seen records from the VA when I shared patients with with a veteran’s clinic or hospital. And I’ve talked to a number of people who are very intimately aware of the VA system. And yes, I think they feel that their system is much more clinically oriented, in the sense that they enter the the EHR, and they’re right away in the space that they need to be. But you’re right. I mean, the essence of a bill, the configuration of an EHR right now is actually a spreadsheet. I mean, if you look at laboratory data, it’s actually a spreadsheet. And that’s why you can sort it from recent, too old or old, too recent, or right to left or left to right. Those are all if you don’t mind the trade name here. Those are all Excel functions.
Nick van Terheyden
Right? really well. Well, what’s Excel? Excel is a business program. That’s a great point. So as you’ve seen this sort of innovation, you’ve you’ve spanned across all of these, you know, I think that the positives, you know, by far, and it’s interesting, you highlight that, that, you know, the the notes weren’t available. I remember that as that was a whole section in the outpatient clinic here are all the the people that we don’t have notes for, I mean, wow, what a tragic thought. But we don’t have that anymore. We look at the way that things are developing now. You’re obviously focused medical informatics, if that wasn’t something that existed, but it’s now sort of central to everything that you do. Where is this going? I mean, where do you think we can go from this point? Have we finished you know, we’ve, we’ve solved all the problems, we’ve delivered electronic medical records, it’s time to sort of pack up and go home.
Dick Schreiber
Now we’re nowhere near finished. Here’s my vision. I’ve had this vision for a number of years. And some of it’s actually coming true, not by me, but by others in the field. My feeling is that the EHR and everything in it should be a byproduct of the visit. And the way to get there is and here’s the dream, I walk into a patient’s room. My identification tag, recognizes me as I walk through the threshold of the door, welcomes me into the room introduces me to the patient in the bed. And knowing my preferences, flashes up on the screen, the patient’s most recent vital signs, their blood sugar’s if they’re diabetic. The last note that I wrote, maybe a new image report that I hadn’t gotten. It’s all right there on the screen as I walk in. I’m conversing with the patient. Sure, there’s some social interaction that has nothing to do with with medical care, per se, but I’m getting to know the patient, maybe the family’s there, we talk a little bit and as I’m going through my history, my exam, it all gets recorded through natural language processing, and any other techniques that enable the generation of a note. And then as I’m talking with the patient, I’m telling them well, this test is better this test is worse, I’m going to repeat a blood count or whatever the test is, we need to get an X ray of suction. So because of this reason, and those are all generating orders, and documentation that I reviewed all those results, then I’m talking with the patient answering their questions, addressing their concerns, speaking with the family, whatever else is necessary. machine is generating my note is generating my orders, I need to look up at the screen and validate and verify. And when I walk out of that room, I’m done. That’s it. And all of those results, all of that information goes directly to the patient portal so that the patient can have a written record of what we just talked about the results, everything at their disposal, so that the next time I come in, they can say, Hey, why don’t you talk to me about such and so but I didn’t understand it. Tell me more about whatever. And we can go over that. And that gets documented. So that I’m not having to do the mechanics of the search, and documentation and ordering, I can focus on the patient. And the machine, electronic record knows our conversation. And I can validate and of course, I can edit and improve upon that. But the important concept here is I can enter the room and have what I need at my fingertips, I can leave the room, knowing that I’m complete.
Nick van Terheyden
How far away is this?
Dick Schreiber
I don’t know. Certainly, many years, when I first got into informatics, which was to that officially was 2005, I started dreaming like this, we didn’t really even have RFID. Or at least it wasn’t any good. We didn’t have any suitable natural language programming. We didn’t have what one company calls a virtual scribe, we had scribes. But we didn’t have a virtual scribe, well, all of those things now exist. And there’s no reason that some smart, you know, 20, something, can’t take my RFID and put on a screen my preferences for what data I want. First thing. So I think that might be no in the near future. But putting this whole picture together. no fewer than five probably more like 10 or 15 years. But that’s not bad. That’s not bad.
Nick van Terheyden
So I think what you’re saying is that from a perspective of clinicians, still, there’s still plenty of work to do.
Dick Schreiber
Oh, yeah. Oh, yeah. I think anybody entering into the field of informatics has job security.
Nick van Terheyden
And as you think about your future, and you know, the future of the people that come behind, what are their main areas of focus? What should they be thinking about? What should? Why should they focus their time, do you think?
Dick Schreiber
Well, there’s a lot of engineers coming into medicine. And I think engineers have an advantage over some of the rest of us because they they have a systems way of thinking. They think in terms of what is connected to what. And I think if we have what my boss calls CES, since I can’t even say it systemness think in terms of the larger structure that doctors interact with the patients, of course, but also with nursing and laboratory personnel and physical therapists and pharmacists. And the whole gamut, if we can think in terms of that larger picture, and include in that our informatics analysts and others who are good at programming and others that understand the clinical parts of informatics. If we can teamwork that, then I think that should be the focus of people coming up to replace me in this business.
Nick van Terheyden
It’s interesting, you you’ve finished with that, because as I look at the existing medical student recruitment process that hasn’t changed in years, it still remains the same assault course. You know, the requires, in fact, it’s gotten even harder, I would say, whilst there’s some suggestion of looking outside of the traditional sciences and so forth, that’s an especially hard path to take for people to do. So maybe we should be focusing on medical education and you know, that aspect of it to change the way that we recruit in or is this a different recruitment pathway?
Dick Schreiber
I think things like stem training is still critical. I believe that the humanities is absolutely critical to all the clinical bedside medicine. But I also believe that we need to encourage people who are creative and more right brained to come up with new ideas, because in the absence of new ideas, we’re stagnant.
Nick van Terheyden
Interesting. I agree. I mean, I think we have to change the way that we bring folks in and, you know, it starts at that sort of early age to sort of broaden the perspectives, but that remains a continued challenge anyway, one that will keep people invested for many years to come. Unfortunately, as we do, every week, we run out of time, so it just remains for me to thank you for joining me on the show. It’s always a pleasure to catch up, Dick. I’m excited about the future and the future you paint. So thanks for joining me on the show today. Thank you for the invitation. Again, it was a pleasure and it was a lot of fun.
