“Teachable moments,” education experts tell us, are events in which reality stares us in the face and ignorance is no longer an option. Where the rubber meets the road. Hell breaks loose. When things get real.
Teachable moments are when we’re most open to new ideas.
That’s why there’s so much interest among medical education professionals in context-sensitive content—communication algorithmically triggered by what an audience is looking at—and why electronic health records (EHRs) are such a tempting medium. When a teachable moment occurs in a doctor’s life, we want to be right there to help with relevant, evidence-based information about our clients’ products.
And if a teachable moment is occurring for a doctor, chances are good there’s an EHR close by. Anything that goes wrong in a patient, any unanswered diagnostic question or unexpected response, has to go into the e-chart. Doctors today spend about half of their work day on activities related to EHRs, from reviewing labs, images, and vitals to issuing orders and e-prescribing medications. Each record is a document fraught with medical and legal consequence.
Imagine how much impact you could have if educational content relevant to the patient’s condition was right at the doctors’ fingertips as he or she goes to the chart. As educators, what better place could there to be than the place where medical learners are confronting challenges? Patient care could benefit immensely if relevant evidence and insights instantly appear when doctors are most open to ideas, and innovations would flow to the real world faster. It’s an enticing temptation to medical education people, many of whom are now beginning to explore this avenue in earnest.
While it’s still a dream for most of us, already EHRs can prompt doctors with expert clinical decision support (CDS) at the point of care. Such capability is a Center for Medicare and Medicaid Services (CMS) “meaningful use” Stage 2 requirement. “Eligible providers must implement five clinical decision support interventions related to four or more clinical quality measures, if applicable, at a relevant point in patient care for the entire EHR reporting period, and have enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period”, according to CMS. Type in a patient’s diagnosis (ICD-10) code on these systems, and up pop guideline-supported treatment options adopted by the institution. (Some even require the doctor to document in the EHR a rationale for choosing an alternative not in the guideline—a line of defense should the lawyers start looking.) The same kind of technology that enables Netflix or Amazon to suggest titles you might enjoy based on key words in titles of what you’re currently viewing is being explored to serve up relevant learning opportunities on-the-spot to doctors confronting complex cases. FDA recently (December 2017) released nonbinding recommendations to help provide guardrails along this rapidly-emerging path. Importantly, CDS functions that are purely informative (rather than interpretive of images, for example) are deemed outside of FDA’s device approval regulations.
Yet educational offerings originating from medical manufacturers—pharmaceutical makers, diagnostics companies, device developers—haven’t been widespread so far on most EHR screens. Doctors may find banner ads for pharmaceuticals on EHR startup screens or e-prescribing screens, but once they have opened a patient’s file they typically all go away.
That may be beginning to change. A 2016 article by John Kontor, MD published by The Advisory Board describes an initiative launched by the maker of a new anticoagulant together with a large provider organization to create an EHR-enabled care model for patients at high risk of stroke. And vaccine manufacturer Merck has funded a Population Health Management program through EHR vendor Practice Fusion that prompts physicians about a patient’s eligibility for vaccinations.
But just as some medical institutions increasingly bar professional sales reps from their halls, some seem keen to keep industry at arm’s length from their doctors’ EHR screens. Note that the currently leading outside provider of EHR-linked clinical decision support, UpToDate from medical publisher Wolters Kluwer, gets to play beside the EHR by explicitly shutting the door on industry. Their website states, “...we never accept funding from pharmaceutical companies, medical device manufacturers, or other commercial entities.” Clearly, we need to work to overcome the distrust with which our industry is viewed by some in institutional medicine.
There’s a fine line between educating a physician and taking responsibility for the patient’s outcome; the learned intermediary is only as good as his or her learning. We’ll need to be ready for the ethical and legal consequences if we want to stand by the patient’s bedside offering medical options to the doctor. It’s all the more reason to continually keep the work we do at the highest standards of science, ethics, and human kindness.
EHRs are here to stay. It’s an exciting time to be at the forefront exploring integrating medical integration into them... and a teachable moment for our industry.
Arndt BG, Beasley JW, Watkinson MC, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data a time-motion observations. Ann Fam Med September/October. 2017 vol. 15 no. 5 pp. 419-426. doi: 10.1370/afm.2121.
Centers for Medicare and Medicaid Services. Clinical Decision Support:
More Than Just ‘Alerts’ Tipsheet. https://www.cms.gov/regulations-and-guidance/legislation/EHRincentiveprograms/downloads/clinicaldecisionsupport_tipsheet-.pdf
US Food and Drug Administration. Clinical and Patient Decision Support Software Draft Guidance .Document issued on: December 8, 2017. https://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM587819.pdf
Kontor J. How EHRs can enable provider-pharma collaboration. Advisory Board IT Forefront. September 16, 2016. https://www.advisory.com/research/health-care-it-advisor/it-forefront/2016/09/ehrs-and-pharma
News release. Practice Fusion Announces Positive Results of Population Health Vaccine Initiative Conducted in Collaboration with Merck. January 14, 2015.