Tar Pit: Adaptive mutation for EMR evolution and medical system survival

Post date: March 29, 2019 by Kim Pittenger

Let’s say you’d like to compare two doctors to find a new primary care provider (PCP). You are a Boeing engineer. You practice lean production methods, kaizen, on the Boeing 737 line. 

Dr. Craft has a nice assistant who weighs you in the hallway but doesn’t say your weight out loud. You remark that their scale seems to add five pounds to your weight or maybe it’s those wet clothes. The assistant invites you to the exam table and chats amiably while measuring your blood pressure. Hmmm … 135/88, substantially higher than you remember. You get about 15 minutes to scan magazines from last summer before Dr. Craft whisks in and apologizes for keeping you waiting. She shakes your hand and looks into your eyes briefly before turning to the computer screen against the wall. She sits sideways to you and counts off the concerns you’ve shared with the assistant as she signs onto the software, Mel’s PrettyGood EMR. You start detailing those concerns, and she types away while interrupting you with brief clarifying questions. Intermittently she turns to you and flashes a smile then pivots back to the screen and puts her neck through a 360-degree stretch. After several repeats of this sequence, Dr. Craft pops up and begins an exam, sprinkled with more questions. After a few minutes, she summarizes your problems and states her recommendations for tests and some lifestyle changes. She returns to the computer, does some keystrokes, sighs, and closes it down. You ask a question or two, get some quick answers, and her hand is on the door. She says your meds will be at the pharmacy later today and the test results will come to your portal account soon, then you’ll both decide what next steps are.  

Before your next PCP selection visit, you read Atul Gawande’s article in The New Yorker, “Why Doctors Hate Their Computers” (November 12, 2018). You remember Dr. Craft sighing and the good-not-great visit you had. 

On your visit to a second PCP, Dr. Veltiosi has an equally nice assistant who invites you into an exam room and has you sit in a chair by an ovoid table. You both look at a computer screen while she taps in your concerns, checks your medicines, and asks you to uncross your legs while you sit there (crossing your legs raises blood pressure, she explains gently, so she wants your feet flat on the floor). She applies a blood pressure cuff on your arm and changes it for the correct size, then gets 125/78. Then she weighs you with shoes off using the scale in the exam room. She reminds you that your colonoscopy is overdue and notes that this will be an added item in your visit agenda. In about 10 minutes, Dr. Veltiosi enters and smiles while shaking your hand and fixing gazes. She sits opposite you, hands on the table. You face each other as she confirms your concerns then asks some clarifying questions. She signs in and shows you the list of diagnoses in her note to make sure that is all and asks if she can just punch in that order for colonoscopy so you’ll get a scheduling call. You say yes. She asks more questions while facing you, then has you up on the exam table for a brief exam, then you’re both back at the table. She shows you some diagrams online about your concerns and asks you to make some choices about what’s next. You part with a plan and receive a colonoscopy scheduling call later that day. 

About those lab reports. Dr. Craft gets those to you in 3–4 days. You saw from the email that she sent it at 9:50 pm. You read your visit note online and see that it was finished at 6:30am on a Saturday. She evidently works from home during the “pajama” or “red wine” hours and has “dates with the EMR” on weekends. 

Dr. Veltiosi gets labs to you the next day and you note the message was sent at 11:15am. Her note was completed the day of your visit, about one hour after your visit. You worry about Dr. Craft and you have warm feelings for Dr. Veltiosi 

You think back to the Atul Gawande New Yorker article. Yes, Dr. Craft might hate her computerDr. Veltiosi seemed to have an easier time. She will be your new PCP.  

Here’s what’s happened on the medical care team’s “line. The EMR software has increased the cycle times of almost everything the care team does in the office. Screen time is up and face time with patients is down. A provider’s length of day is longer too. Many providers, Dr. Craft likely among them, put kids to bed and finish their work from home. This does not enhance family unity. In addition, medical folks train to craft their best interaction with patients. Since the EMR is largely transactional, more of their time with patients is now spent in transaction, not interactionProviders feel less joy. To cope, they reduce their FTE status. Access suffers. What we dreamed would be a computer-enabled upgrade has instead been a “degrade.” 

We always dreamed the EMR would be intelligent, programmed with jidoka. That’s useful “knowledge built-in,” to mistake-proof care and transfer work from the professional to the machine, shortening the work day. EMR software constrains work flow, adding steps and clicks. The jidoka, the intelligence built into the EMR, currently enables mainly better coding, reimbursement, and compliance functions, while adding minutes to the work day. Again, a degrade. 

In his New Yorker article, Dr. Gawande suggests that our medical system is an evolving entity, one that evolves by mutation, improving with each advantageous mutation. Dr. Veltiosi has adapted to the mutations forced on her by the software and has been selected to have a sustainable life, completing her work while in the office, apparently. Dr. Craft has been mutated negatively by the software. You suspect that her office set-up and management of the workload are much less advantageous than Dr. Veltiosi’sYou, like Dr. Gawande, wonder if the software causes negative selection of doctors into less sustainable work patterns, more negative selection than adaptive mutation. Some call this the “tar pit” for the medical species. 

Lean practitioners can see that the rigidity of the EMR selects for the most facile and dogged users who can tolerate its rigidity and find their own workarounds to survive. It selects for survival while increasing documentation, billing, and length of day. Providers reduce their access and FTE status to manage work-life balance. Dr. Veltiosi (whose name means “improvement” in Greek, by the way) and her team have applied kaizen to their practice. They have engineered external set-up of the entire visit, spreading the details of the visit tasks across the team, so it appears smooth to the patient. They work in flow, processing results, messages and refills in between each patient visit instead of batching them before and after work. They have standard work that enables evidence-based practices such as accurate blood pressure measurement and health maintenance (even colonoscopy) at every visit and in between. Even their exam rooms are designed to join the patient in the “golden triangle” with the computer screen, to harness the EMR for work with the patient. Dr. Veltiosi and her close colleagues have given each other permission and coached each other to document briefly and to the point.  

These are all methods we coach to at Rona Consulting Group (RCG), the lean consulting practice at Moss Adams. Our kaizen events and system transformation enable adaptive mutations for sustainable practice and improved quality for all. Is there hope for actual improvement in the EMR software itself that could improve the flow of care?  

  • Lean Gap-IT workshops help organizations diagnose their gaps in process steps that need development before EMRs are configured.  
  • Operations improvements for human operators need to be timed and assessed for their ease of EMR use and testing better techniques. This is basic lean stuff. 
  • Dr. Gawande and others hope that the emerging application programming interface will help. It would allow clever “apps” to sit on top of the vendor’s platform, innovating around the platform product’s rigidity, for faster workflow and mistake-proofing. While most EMR vendors I have met admit their products were not “built for workflow,” adventurous provider groups can customize the vendor’s product and improve workflow.  

Enter lean. Lean uses “standard ops” to quantify time and difficulty, exposing waste. It can be applied to digital operations in the EMR. Kaizen exposes inflexible systems and hard-to-do operations that need redesign. Lean drives adaptive mutation via the creativity exercises and idea generation inherent in kaizen. Kaizen then tests mutations via PDCA (plan-do-check-act, a cyclical four-phase application of the scientific method) and harvests those that are advantageous, selecting our client for survival. 

Can we find partners who want to apply standard lean observation and quantification methods to common EMR tasks? Each EMR has an embedded running clock that could be programmed to measure key task cycle times such as visit duration, time in documentation, and time in messaging between visits. Kaizen methods can reduce unnecessary time and improve quality of processing per time spent. Providers with substantial after-hours processing time can be helped to choose improvement paths such as EMR shortcuts training or documentation reduction, choices other than shrinking time with patients and family. EMR software widgets that perform poorly can be exposed for true upgrade. 

Our partners wish to go beyond Mel’s PrettyGood EMR, to find the blend of human and digital changes that will mutate the work and the EMR, not the people. Kaizen will make work sustainable. Are you ready?