PCL Experts: ER Doctor Describes the Day-to-Day Hurdles of Disorganized Patient Care

VectorCare was recently able to speak with Andy Barnett, a board-certified physician in family & emergency medicine as well as full-time faculty member at the Oregon Health & Science University (OHSU) in Portland. As a physician who specializes in pre-hospital care and medical necessity around transport methodology, Barnett was able to speak to some of his main logistical pain points day to day as well as how technology can affect the future of healthcare.

Some quotes have been edited for brevity and clarity

VC: Thanks so much for taking the time to speak with us. As an ER doctor, you’re able to be on the front lines of care delivery. In terms of Patient-Care Logistics, what are the major pain points you see day-to-day in your practice?

Patient Transport Timing

“When I work in a rural emergency department, they do a fair bit of patient transfers from there to a facility with a higher level of care. And in those cases, my pain point has been the time of arrival for transportation, because in smaller hospitals we have very limited capabilities. As an ER doctor, I’m usually the doctor with the highest level of critical care, and while I can keep you alive for an hour, after that you’re going to need an intensive care provider. If I’m unable to get patients out of there in 30-60 minutes, it can start to impact patient lives.”

Lack of Visibility around Transportation Options

“There’s also a little bit of a pain point for me around, as an ER Doctor, being forced to choose between ground and air transport for a patient. Ethically, I’m expected to not really factor cost of the equation and do whatever it takes to save the patient’s life.

However, if it’s not going to make a difference then we don’t always have to go the fastest route. Then I’m left asking the question: What is the air versus ground decision making difference? Give me the side by side with traffic, weather, and all other factors at play. Then we can decide if that difference in time is going to make a difference to the patient.

This is something I believe we can improve with new types of technology: having a realtime, side-by-side comparison of different transportation options for a patient.”

Paperwork

“After-action paperwork can drive me a little crazy. I’ll frequently arrive from a shift and have two or three messages in my inbox from a billing company asking me to make an addendum to a chart. Once you sign and close a patient’s chart, it seems to eliminate a space in your brain for that decision making process. If you have to go back in and edit a chart, it includes a surprising amount of cognitive load. Like any machine, your brain can only handle so much load. The more things you load onto it, the less effective your brain will be at individual tasks.

"If you have to go back in and edit a chart, it includes a surprising amount of cognitive load. Like any machine, your brain can only handle so much load. The more things you load onto it, the less effective your brain will be at individual tasks."

If I’m trying to work and am mentally loaded with having to justify treatment for patients I treated weeks ago, I have to mentally reengage that patient. I have to reopen that file, create the space in my brain for it, then re-engage with that chart. The overall time might only be a couple minutes, yet it’s another cognitive load that I have to get through when I should be preserving what I have for the patient in front of me. Often, administrators don’t get why this paperwork can be so painful.

So we should focus on anything that can be done to alleviate paperwork for the provider or at least ensure the workload happens upfront. I know that providers may complain about extra paperwork in the middle of the shift, but it’s worse to have to do that paperwork two weeks later. No question.”

VC: How do you see technology changing the way you deliver care?

The Good

“From a 10,000ft perspective: it will mean improved quality of care because it allows doctors access to more data.  I'm a big believer that more data about my patients allows better care. If you're facile with it and you can access all that data quickly, then the quality of care improves dramatically.”

The Bad

Once downside of this, however, is efficiency expectations for physicians.

“All new technology, like physician order entry, has increased our efficacy. But the productivity demands for physicians have gone up. My quality of care has gone up because I have access all this additional data, but then it takes additional time for me to access and read that data. To provide the best possible care, I’m obliged to sit and look at your chart and review all studies and data related to your record, but this takes time and lowers my efficiency. The healthcare system never accounted with this shift in efficiency expectations with the rise of new technologies.”

VC: What do you envision is coming down the pipeline in healthcare's future?

• A Universally Portable EMR, integrated databases that allow care teams to pull patient files from any facility in the country.
• Patient-targeted therapies will begin to become more widespread. Therapies will be designed based on your DNA, and will be genetically tailored.
• Increasing numbers of best practice providers. PA’s and nurse practitioners will be performing more care delivery, supervised by increasingly subspecialized physicians.

Most importantly, Barnett chatted about a trend toward the Quadruple Aim of Healthcare. The Quadruple Aim adds an Improved Clinical Experience to the aims of healthcare. To improve the value of healthcare, we first need to improve the quality of life for frontline care teams: less cognitive load, burdensome paperwork, and more reasonable productivity expectations. Barnett explains:

“As organizations strive for the triple aim, they expect more and more out of the care delivery system and provider teams. Their job satisfaction and quality of life will plummet. Without this, we’ll end up with miserable providers who are incapable of delivering care”

“As organizations strive for the triple aim, they expect more and more out of the care delivery system and provider teams. Their job satisfaction and quality of life will plummet. Without this [The Quadruple Aim], we’ll end up with miserable providers who are incapable of delivering care”

A Reflection: Patient Care Logistics’ Role

A properly organized Patient Care Logistics system should do the following:

• Set medical necessity parameters before ordering treatment or services. Ensure that the patient meets condition for medical necessity before ordering a service. With technology, this process can be automatic and make certain that doctors don’t have to prove medical necessity after a service has been ordered.
• Auto-document every step in the patient’s journey. Physicians should no longer carry cognitive load due to having to remember patient treatment from weeks ago. Patient Care Logistics leverages realtime data to document each activity from a patient service so that every member of the care team can view and report on a patient. (fix this sentence later)
• Enable a marketplace to choose the best providers for the job. When ordering a service, such as patient transport, physicians need realtime comparisons of the different provider options. When you’re deciding between air transport and ground transportation for a patient in critical condition, knowing how much time each will take, side-by-side, in real-time, can make all the difference.

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Want to read more from the Patient Care Logistics Journal? Check out our latest post, a guide for NEMT service providers on how to grow their business.