key: cord-030903-hhhjwoei
authors: Sinsky, Christine A.
title: Implementing Telemedicine in Primary Care: Learning Lessons From Electronic Health Records
date: 2020-08-27
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.07.017
sha: 
doc_id: 30903
cord_uid: hhhjwoei

nan

Christine A. Sinsky, MD T he common narrative is coronavirus disease 2019 happened, payment and policy barriers were quickly lowered and voila, telemedicine, a technology for which adoption had been slow over the past decade, is, within a matter of months, in widespread and successful use. Fait accompli. On to this narrative has been grafted the hopes that telemedicine will solve other persistent problems, particularly in primary care. 1 As with any other technology, the divine is in the details.

The challenges for primary care are deep and structural. Inequity in payment for cognitive versus procedural care 2 ; conflating how primary care has been valued with its value; equating the payment allocated for primary care services with the difficulty in their mastery (contributing to the assumption that lesser training is of little consequence in primary care); and a shrinking scope of practice for physicians within the specialty are among the reasons our health system has not benefitted fully from what a well-supported, well-organized model of primary care has to offer.

Certainly, telemedicine cannot solve the structural causes above, but can it improve capacity and access while also reducing time pressure and burnout? If this is possible, what are physicians and their teams doing during now inperson visits that is not necessary and could be eliminated? Arguably, it should require even more time rather than less to accurately read the fewer signals available from patients during a video visit and to be sure that the real reason for the visit, the third or fourth complaint, reaches the surface.

Twenty years ago, electronic health records (EHRs) were anticipated as a technology that would improve quality, efficiency, and professional mastery. All of our patients' information would be at our fingertips whether we were at the clinic, the hospital, or at home. Clinical decision support, popup reminders, and hard-stops during order entry would make us better physicians.

And yet the EHR was not the savior of primary care, 3 but instead, for all of its benefits, its burdens fell disproportionately to primary care physicians. Many tasks take more time when performed on the EHR. 4 In addition, with the mistaken beliefs that technology will allow the physician to do other role types, work and that this work can magically be accomplished in the interstitial time between other work, time pressure for physicians intensified after EHR implementations. Tasks previously managed by receptionists, transcriptionists, medical records clerks, et cetera, have been shifted to physicians; work has spilled over into home, 5 stealing time from family, friends, and personal well-being 6 ; and the EHR provided vastly more opportunities for monitoring, measuring, 7 reprimanding, and penalizing physicians.

What are the lessons learned that could ensure that similar stumbles do not befall the promising technology of telemedicine? Design, Implement, and Regulate With Teams in Mind In each encounter, whether in-person or video, there is too much to be done by just one person, and it is too important to leave to chance. The doctor cannot singlehandedly do all the work of the visit and do it well; this mindset blinded many to the risks to patient safety, patient trust, and professional well-being associated with many EHR implementations. There is no need to repeat those mistakes with telemedicine.

Providing patients undivided attention is one of the most powerful tools in any physician's toolkit. Multitasking, which is really task switching, 8 is hazardous. During a remote visit, because there are fewer cues to read, the physician must be fully attentive to all available, rather than simultaneously transcribing the visit note, entering orders, sending medications to the pharmacy, ticking off performance measures, and composing the billing invoice. Humans have a finite cognitive bandwidth; the more time spent on clerical tasks, the less available for deep clinical work.

Health care is not just a series of transactions for which anybody will do, but is built on relationships. Diagnostic accuracy and therapeutic adherence are greater, and waste reduced, in the context of a trusting ongoing relationship. 9 Telemedicine is not inherently transactional, and by bringing the physician and team closer into patients' lives it can support and enhance relationships. To realize this potential, however, a priority must be placed on continuity and relationships.

It is important to avoid thinking that a physician can somehow do more in less time during video rather than in-person visits. Work that physicians and others perform outside of the encounter is still work and takes time. Likewise, work that occurs at home is work, and deserves to be counted. Some tasks are quicker when done with a technology assist and at other times work on a technology platform can take more time. It all needs to be counted and understood.

Invest in the Science of Practice Teamwork, planning, and efficient workflows are essential. Not every problem is best suited to a technological fix. In fact, technology, such as artificial intelligence, 1 used to compensate for an underlying disorganized system of care 1 can be cumbersome and costly.

For example, appropriately scheduling patients from the outset saves time and improves patient experience. At the end of today's appointment, the team can set up the next appointment, with all associated tests for prevention and chronic illness monitoring, customized to this particular patient, accommodating the patient's preference for an inperson or virtual appointment. 10 No need then for a last-minute "schedule sweep" 1 to cancel the patient after an algorithm deemed their appointment unnecessary.

Likewise, centralizing population health as the primary vehicle for prevention and chronic illness care can be an unnecessary source of further fragmentation, 9 depersonalization, and waste within the health care system. Instead, using an organized system of care, all of the patient's annual needs for prevention and chronic illness monitoring can be arranged at a single, coordinated appointment rather than being fragmented, with the patient contacted 1 month for their mammogram, the next month for their pneumococcal vaccine, and at yet another time for their urine test for microalbumin. A registry, whether managed centrally or more personally at the local level by the patient's team, can catch those patients who fall through the cracks of an organized system, but to use it as the primary vehicle by which to manage populations is cumbersome and reduces customization at the level of the individual experience.

During the storm that is coronavirus disease 2019, telemedicine arrived with a bang and is thankfully here to stay. It will take time to understand all of its risks and benefits, the appropriate patients for in-person versus virtual care, and to develop the optimal models of teamwork for this platform. Let us not repeat the mistakes encountered when EHR implementations were anticipated through rose colored glasses, but rather look with clear eyes to the lessons from the past generation's technology challenges.

Retooling Primary Care in the COVID-19 Era

Medicare payment for cognitive vs procedural care: minding the gap

E-nirvana: are we there yet?

Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations

Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties

Electronic health records and burnout: Time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians

US physician practices spend more than $15.4 billion annually to report quality measures

Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective

Care fragmentation, quality, and costs among chronically ill patients

Putting pre-visit planning into practice