Michael R. Mcguire, Kuruvilla Mathen

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Changing the Way Physicians Work in Order
to Improve Patient Care

Michael R. McGuire, Kuruvilla Mathen

Universal Patient Medical Record Forum, Berkeley, CA, USA

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Received March 10, 2015

Copyright © 2015 Michael R. McGuire. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accordance of the Creative Commons Attribution License all Copyrights © 2013 are reserved for SCIRP and the owner of the intellectual property (Name of the author). All Copyright © 2013 are guarded by law and by SCIRP as a guardian.

Abstract

In the future each patient is likely to have a complete patient medical record, combining medical information from wherever the patient was seen for care. In addition to describing how this practically could be done, other capabilities are proposed that in combination with a complete medical record for a patient would improve medical care over how it is practiced today. These changes would require physicians to do their work somewhat differently. These changes in the way physicians do their work could be incorporated into the curriculum of medical schools.

Keywords

Universal patient medical record; electronic medical record (EMR) system; virtual organization; case; episode of care; consulting pharmacist; early-treatment disease; public health; centers of medical expertise; personalized medicine; public health

1. Introduction

Currently, medicine is practiced one encounter at a time. Although this approach is appropriate for most situations, it is inappropriate for chronic conditions and complex medical care which extend over many encounters. Proposed are changes to the way medicine is currently practiced to take care of these more complex situations.

To be successful, these changes in the way medicine is practiced for chronic and complex conditions must be straightforward and not overburdening to physicians. These changes must be incorporated into the curriculum of medical schools.

Some of the changes presented assume that in the future a patient’s complete medical information will be available to all medical organizations where the patient is seen for care. I call this capability a universal patient medical record (UPMR) [1-3].

2. Support for Patient/Physician Communication

Patient/physician communication is currently inadequate for complex medical situations. When a patient comes in for care, the patient usually receives advice, but the advice is often forgotten within a short period of time. Conversely, a physician relies on a patient’s sometimes faulty memory and a usually unorganized medical record to gather information to diagnose and treat a problem.

I propose three forms of information to enhance this communication:

1)An analytic summary

2)Aclinical summary

3)Aself-care checklist.

An analytic summary is crucial information about a patient that every physician should know (e.g., the patient is a T5 paraplegic). At the start of each encounter, the physician will be shown the analytic summary.

A clinical summary would summarize past care for the patient, including significant health problems, current medications, current and future preventative care activities (e.g., vaccinations), allergies, and a list of all past encounters for the patient. Selection of an encounter would identify and allow retrieval of all medical record documents for the encounter. The clinical summary information would be of use both to the physician and the patient.

A self-care checklist would be created for the patient by a physician, identifying what steps the patient should follow to keep healthy and to identify when to contact a physician for care. A self-care checklist is most often used when the patient has a major manageable long-term medical condition. A self-care checklist is an offshoot of Atul Gawande’s idea to have surgical checklists for surgeons [4]. A self-care checklist does not need to be part of the UPMR.

A clinical summary would be a major part of the UPMR.

In the future, each medical organization would enter medical record information through an electronic medical record (EMR) system. Large medical organizations might have their own EMR system that interfaces with their encounter (hospital and outpatient scheduling), pharmacy, clinical laboratory and other systems. All other medical organizations would use EMR systems that serve similarly to an electrical utility, buying time for use of the EMR. See figure 1.

Physicians caring for a patient through their EMR systems would provide information for the clinical summary for a patient stored in the UPMR through UPMR services provided to EMRs through a secure healthcare network available only to certified EMR systems. Through the services provided by the UPMR, an EMR system could then retrieve the clinical summary for the patient with the combined patient information..

3. Information to Evaluate Care: “Connecting the Dots”

Diseases progress, or are resolved, over time. For example, a patient with a knee fracture might have an operation to repair the fracture and function normally after recovery, later get arthritis, later be unable to run, later find it difficult to walk, may then start using a narcotic, may then have a knee replacement, and might later have the knee replacement corrected.

Figure 1.Large organization and utility EMR systems (Reprinted with permission from reference [3]).

I propose that this progression of a medical condition for a patient, which I call a disease history, record all following medical conditions (outcomes), associated procedures and other associated interventions (e.g., prescribed medicines for a medical condition), and patient identified outcomes (identifying the patient’s current determination of his disability as a result of the medical condition).

At the end of each patient encounter, a physician would be asked if a new medical condition or intervention was associated with the original medical condition or a following intervention. A patient would periodically be asked to evaluate the current outcome of the medical condition based upon disability measures.

Recording the disease history for each major medical condition for each patient would (1) enable physicians to be identified who have a significant amount of bad outcomes as result of procedures they performed, (2) enable different interventions for the same medical condition to be evaluated and compared based upon later outcomes, and (3) provide information that could be combined with other patient information to enable more accurate prognoses for medical conditions.

Creation of disease histories for a patient requires the existence of a UPMR to store the disease histories over an extended period of time for a patient as the patient is likely to be seen in many different medical organizations over time.

The book Unaccountable [5] describes how recording bad outcomes for major procedures has resulted in medical organizations improving their care.

4. Information to Evaluate Care: “Connecting the Dots”

The book Unaccountable [5] describes how recording bad outcomes for major procedures has resulted in medical organizations improving their care.

5. Care for Chronic and Complex Medical Conditions

If a patient is seen by many physicians for a medical problem as is the case of a patient with a chronic or complex medical condition, it is often the case that different physicians seeing the patient will come up with inconsistent care plans or even different diagnoses [6]. Further, the care plan is written for a single encounter.

I propose that for chronic or complex medical conditions, one physician take responsibility for care of the patient for the patient’s medical condition and that a care plan for that medical condition be written that applies until the care plan is changed, with the care plan under ordinary circumstances also applying to all other physicians seeing the patient.

I propose that two data structures be developed, a case and an episode of care. The purpose of these structures is to contain the following information:

Identification of the individual
Medical condition or procedure for the individual
Managing physician for the case or episode of care
Care plan for the medical condition or procedure
Encounters where care is given for the medical condition or procedure, with the ability to retrieve medical record documents for each encounter.

A managing physician would take responsibility for the care of the patient for the medical condition. He or she would develop a care plan for the medical condition that would be applicable until it is changed, with the care plan possibly lasting over many patient encounters or, especially in the case of an inpatient stay, changing a number of times during the encounter. All other physicians caring for the patient would be obliged to follow the care plan of the managing physician except in case of an emergent situation.

A non-managing physician seeing the patient might sometimes serve as a physician providing a second opinion. In such a case, this information would be sent to the managing physician for evaluation of what to do: to incorporate the ideas into the care plan of the case or episode of care or to disagree with the analysis. Referring a patient to a specialist is one way for a non-specialist managing physician to get a second opinion.

The difference between a case and episode of care is that a case would be for a long lasting or chronic condition, whereas an episode of care would be for a condition that is expected to reach a resolution within a responsible time period. For a case, there may be long periods of time where there is no managing physician, such as for a patient with a knee fracture who has no problems for a long time after recovery from his initial surgery but will undoubtedly have associated medical problems later in life, such as arthritis.

A case or episode of care would insure consistency of care and that one physician takes responsibility for care, at least for a period of time, to insure coordination of care.

At the end of any encounter, any physician seeing a patient having a case or episode of care would be asked if the encounter involved treatment in some way for the associated medical condition. If so, the encounter would be added to the case or episode of care list of encounters. (Note that medical information developed during the encounter would otherwise be recorded as it is today, including development of a care plan for the encounter—this would insure a physician performs his practice much the same way she does today.)

Use of cases or episodes of care does not require a UPMR, but incorporating cases and episodes of care within the UPMR would enable coordination and consistency of care for a patient across all medical organizations where the patient was seen for care.

6. Virtual Organizations

Physicians, especially for inpatient care, recruit other specialist physicians to care for a patient. For example, a patient could come in for care who was driving a car and had a heart attack, and as a result have a head injury and a punctured lung [7]. A general surgeon might recruit surgeons and specialists to work together in the care of the patient with the general surgeon supervising what care is given first. Although these physicians might not work together on a regular basis, their relationship in regards to the patient is an organizational relationship, with the general surgeon serving as the supervisor. I call this situation for a patient a virtual organization.

To describe this virtual organization, I will use the episode of care construct described earlier. This virtual organization could then be represented by a hierarchy of episodes of care. See figure 2. Each physician would develop a care plan for their episode of care, with the general surgeons care plan describing how care is to be coordinated.

Figure 2.Episode of care hierarchy for a virtual organization.

Although not intended to replace physician to physician communication, when the general surgeon makes a change to the Surgery episode of care such as a change to the care plan, the physicians managing the lower level episodes of care would be informed. Conversely, when a surgeon at the lower level makes a change such as a change in a care plan for the episode of care, the general surgeon would be informed.

Because a virtual organization most often occurs within the same medical organization, this approach does not require the UPMR. A virtual organization could however involve physicians from different medical organizations—this would require the UPMR.

7. Consulting Pharmacists

Today, in general, after medicines are prescribed, little is done to later determine if the medications are still necessary. Thus there is likely excess spending on medications by patients, insurance companies, and governments, as well as possible harm to the patient.

I propose that there be pharmacists who, rather than selling medications, provide consulting advice to patients on the medications they are taking. I call such a pharmacist a consulting pharmacist.

A patient taking a large number of medications should periodically meet with a consulting pharmacist to determine if the patient is taking the wrong medications, the wrong dosages, medications that interact or medications that cause side effects. The consulting pharmacist could adjust the frequencies of the patient taking the medications, thus making the process easier for the patient. The consulting pharmacist could then recommend these changes in medications to the patient’s physicians.

Also, a patient might inform a physician of a medical problem that could be the result of a medication side effect (e.g., tingling in the fingers). The physician would have the ability to refer the patient to the consulting pharmacist to determine if a medication was indeed causing the problem.

The consulting pharmacist would meet directly with the patient and have the clinical summary to identify the total list of patient medications and identify the patient’s significant health problems. From the clinical summary, the consulting pharmacist would also be able to view past patient medical record documents.

Also, when a physician is prescribing a medication for a transient health condition, he could associate the medication with this health condition. When the physician identifies that a transient health condition went away, the phsyician could be told of medications for the health condition, allowing her to “unprescribe” the medications, no longer making them available to the patient.

8. Early-Treatment Diseases

There are many diseases that are difficult or impossible to treat once obvious symptoms of the disease appear. In the future for such diseases, especially with the advent of molecular medicine, it may be possible to develop a diagnostic test to predict the disease at an early stage as well as to develop a successful treatment at the early stage.

Colon cancer is a currently such a disease. There is a successful way of early detection and treatment. A colonoscopy detects polyps that could turn into colon cancer and enables removal of the polyps before they turn into cancer.

Alzheimer’s disease is probably one that is impossible to treat once there are obvious symptoms. In the future, a diagnostic test might be developed to predict the disease at an early stage together with a successful treatment to treat the disease at this stage.

Assuming this is the case with Alzheimer’s and other diseases, there could be several potential problems:

1)Timing: The timing of the diagnostic test and treatment may be critical for their success; for example, if the diagnostic test is done too early, then the diagnostic test might not be able to predict the disease, while if the diagnostic test is done too late, then the treatment may be too late to be successful.

2)Diagnostic test complications: The diagnostic test might potentially cause complications.

3)Treatment complications: The diagnostic test might cause false positives, and the treatment might cause complications.

This situation complicates care: High risk individuals may have to be selected and others excluded so risks of the test and treatment do not result in overall poorer health of the community of patients. An individual must give his consent to the test and treatment. The individual may need to be brought in at the right time for the diagnostic test and treatment.