Eva Podcast: Writing Notes & Physician Burnout

Erin – Welcome to the Eva podcast. My name’s Erin. I’ll be your host where we explore all things health, information technology, and Eva, the first interpretive health record system. So, without any further delay, let’s get this episode started. Good morning, Dr. J.  

Dr J – Hi Erin. It is a good morning. This some good stuff is going happen today.  

Erin – All right. Today we will be talking about note taking or also known as charting.  

Dr J – Yay. What fun.  

Erin – Although charting may not seem like the most exciting topic, it’s incredibly valid these days especially when we’re referring to physician burnout and a lot of articles out there right now, including the whole issue of medical economics focused on various forms and reasoning behind physician burnout. And a huge part of that burnout is due to taking patient notes and how difficult it has become to do simple note taking and referrals with current EMRs. So, if you could talk to us about physician notes, about note taking, and Eva and kind of your take on the situation. 

Dr J – Yeah, so, can you blame anybody for not having any interest in doing something that is entirely designed to cause them to be frustrated and unhappy? I mean, the charting at, at one point was the means by which a doctor had an understanding of what was needed by the patient. Where, you know, someone came in today and she has the stuffy nose, but I don’t think it’s anything but an allergy so, she needs allergy medicine and that was it. That was a, that was what documentation was about. But now we have a set of masters that we need to respond to, none of which have direct responsibility for any of the work we do so they’re basically interfering at a very, very high level keeping us from the part that makes us happy or gives us joy, which is, I see a patient who’s sick, I intervene they get better and that’s my job. I, I help people get better. That has been transformed from a job or a career or a calling from that to actually being a, a very overwhelmed, clerical clinical scribe and form filler in so many ways, unless you’re using a system that honors that time, time told tradition of I’m a doctor, I help people get better, and my record helps me do that. It’s a tool that I use to be better at my work. We’ve created the Eva thing because 20 years ago, the frustration for me was so high with getting a good history that it was required for me to come up with a better solution. I was getting tired of sitting and listening to extended stories that were not real efficient. It was an inefficient way, so we found an efficient way to do that. Then we ran up against five or seven EMRs that we hated working with in the next 20 years, and finally decided we had to create our own if we were gonna have an easily accessible, highly efficient system. And, we’ve got it with Eva. It works now, and the tool that it has become the practice platform enables us to do a better job at helping people get well, which is the joy of medicine. So instead of filling out forms and doing charting, which is, I think for most doctors, it’s nauseating, nightmarish, malpractice issues, medical board issues that all, it all circles around that charting and documentation. And it’s difficult because EMRs and HMRs are horrible. They’re, they’re designed by insurance companies and government regulators, accountants and administrators, and none of it, with maybe a few exceptions, is designed fundamentally foundationally by physician and clinicians who actually take care of patients. So, it’s gonna be disappointing. I mean, nobody likes, I, I, it’s hard to imagine how many doctors really like to do accounting or they’d be accountants, you know. It’s, it’s ridiculous. It’s, and the people are unhappy and that, that reflects on then, all of healthcare is negatively influenced because it sucks to chart. It’s just a nightmare. Instead of it being easy and, and effective, it’s, it’s full of so many nonsensical, unnecessary components that it’s just disappointing. Doctors are smart people. They’re doing a very unsmart thing, working with the EMH. EMRs and EHRs that are available. For the most part. I know that there are some that are better than others, but I think Eva’s by far the best because it runs on clinical intuition and flow. It’s how, how doctors think. It’s how doctors work when they want to do a great job for patients and when they want to extract the joy out of out of medicine, which is I see a patient, I get them well and that makes me happy. And the rest of it is kind of like, man, you gotta do some of it, but it shouldn’t be 50 or 60% of your time doing that. Some of it to fill in forms and do all that other junk that an EMR makes you do. So, I’m pretty passionate about it. I, I think that the idea that medicine can be so fun, it can be such a joy to, to do but it, it’s not if you have this incredibly onerous clinical mountain of paperwork to do every day. It’s just, it’s, it’s nightmarish and, and that’s not the only problem that doctors face, but we have a solution for that one. For the EMR/EHR problem. We have a solution. It works. It’s working. Lots of practices around the United States. We are having tremendous success with it. It’s getting better all the time. And we’ve been refined over 20 years. So, saying it’s getting better, is saying something cause we’ve done a lot of refining, we’ve done a lot of making it better. So, anyway, that’s my pie horse. I’m, I’m, I’ll step down off my horse. 

Erin – Well, I’m so glad you’re passionate about it because your passion over the past 20 years gave me faith in the future of medical record systems which is why I begged to be your first clinic before I worked with you guys and bring you into that atmosphere and test out what it was like to build out an Eva for the practice I worked with. Which for me, it was one of the most streamlined processes out there. Now, people who are not familiar with electronic health records or new to the medical world, like front-desk and that, you know, they may find navigating any system cumbersome because it is so different than kind of the modern business world. Should it be, that’s a whole other discussion. But, I wanna focus on, the fact that outside of this, if we chose not to help spread the word of Eva, like if I didn’t join your team, if we didn’t focus on Eva outside of clinical hours we’d do fine. Though we would have a great life financially secure, all of that. But it seems a shame, or it seems almost criminal not to share Eva out there because it has the ability to transform an independent medical practice and make your practice thrive and your staff members happy. That’s so important to me because my best providers for me, for my own healthcare are my independent providers. Not to say that I don’t have great ones in the hospital system, but primary care wise for sure, and they’re incredibly hard to find. So, I wanna say a quote from, you know, the blog that we’ve been working on together and kind of discuss that further because to me it really outlines what Eva’s all about. “Practice software that’s designed around the doctor-patient relationship integrates note taking into the clinical workflow and transforms the experience into a collaborative effort that enables real shared decision making.” And I love this quote because it’s really why I became a nurse. You know, I wanted to participate with patients and help support individuals in their healthcare journey no matter where it was. And I always found, surprisingly, I shouldn’t, it shouldn’t have been surprised by it that the electronic health record kind of got in the way of that. So, can you speak to the Eva experience? So, the Eva experience is not just using Eva as your cloud platform, right? Your electronic health record system. It’s actually a full provider patient experience where you, we suggest that you install touch screens in your patient-room or you have an Ipad and you interact with a patient with Eva, which is this incredible education opportunity for the patient, but it also allows the provider to seamlessly get those notes done because we’ve streamlined the process so much and built Eva literally from the patient provider experience outward. So that’s the main focus and then everything else was built around it. Can you tell me, why? Why did you decide to build it that way? What was the motivating factor there? What inspired you?  

Dr J – Well, here’s the deal. Like, so the idea is you’re, you’re gonna market something and then actually sell it. It’s so the patient is on the bed dying, they’re writhing in pain, in agony, moaning, and you say, oh, you know what? I figured out exactly how to treat this infection. There’s this new drug called penicillin and I’m gonna use it. And then, well, are you gonna make, are you gonna actually make a living off of selling, selling penicillin? Well, yeah. I gotta make a living doing something, so yeah, I’m gonna do it. So, ah, the patient right now, that moaning, writhing patient is the medical profession and what’s killing them is horrible, horrible electronic health record systems. They’re horrible. They’re so bad. It is the number one cause of burnout. Burnout supposedly is gonna decimate the professional. They’re gonna lose 10 to 20% of all practicing doctors in the next two or three years. They say that it’s never true. It’s always lower than that cause a lot of people fuss and moan when it comes down to it they don’t do it. But this is a serious problem. This is something that the patient is the medical profession. They are writhing and kicking in pain. Oh my God, we’re gonna die here. And I say, Hey, I have some penicillin, some electronic health record, penicillin, I can give you this, this product, and it will cure your problem. To not do it would be evil. To not do it would be negligent and so unbelievably unprofessional and unkind. It’s just so the product that we’re offering, what it does is it actually restores the only part of medicine that makes it rewarding is healing. You’re healing people, you make people better. So that idea of collaborative activity, this touch screen on the wall, a patient who’s not engaged in the process is who is pretty passive or who is being just shuffled down a cattle chute where they’re getting treated but not engaged, doesn’t do nearly as well. That’s known. Everyone knows that the engaged patients better. We talk about shared decision making, shared decision making, it’s a novel concept in medicine because the paternal doctors kind of the norm for the last thousands of years, but that’s not the case anymore. We have the internet. We can talk, Dr. Google helps a lot, patients wanna have that information. We have to do something different to share. One of the ways is a touch screen in the room, which is it’s it’s an investment, maybe a thousand dollars, I don’t know it’s for a good one. But to do that, every patient who’s involved from then on gets to see everything that you’re talking about directly so that you’re sitting with the patient in front of the screen instead of sitting behind a screen with the patient looking at the top of your forehead and the back of your computer.  It’s designed for that, Eva is designed for that purpose. It doesn’t happen to a regular EHR that you turned around and showed the patient, which would be worthless because they’re so ugly and filled with these things that look at Excel spreadsheets everywhere that no one, including the doctor can fully understand without getting a headache. So, we’re looking at a complete redo or complete rewrite of the whole process of making records, creating records. The record is created with the patient involved in the moment, in the room at the time of the service. Some of the details I’ll dictate later. Some of the, if it’s a involved history and really big story, I may take it aside and do it for two minutes in my office because all the framework is done all the, all the two by fours and all the structures all built, and all I have to do is pop a couple nails in them, some drywall and finish up. That’s my job as, as the clinician and the EHR that we’re looking at from other settings. In no way could you spin it on a little tripod and show somebody that screen. It would be unhelpful. And with.Eva, it’s all designed to be processed that way so the doctor can easily access it. And if the patient wants to be engaged, the patient can easily access it and they can be taught from their lab, from the notes, from all of the data that’s available. In an open notes format, we have open notes that we’re training them in the room. This is what Open Notes is for. See this big screen, this is what you and I share as patient and doctor. We work together and this is all yours and all mine. And it’s by law the Cures Act last year, you have to have open notes. It’s required Nobody is training patients to do it like we do. No one has a system that’s designed for that purpose. They have a portal, but the portal invites the patient into a very limited experience of the whole thing. They get a few lab results and they, they may see when their appointments are and have been, but nothing like Eva where they have complete ability to graph their findings in their lab. They can look at every lab test they’ve ever had. They can look at every note that’s ever been written. They can look at every time they cancel an appointment, kept making everything. Everything that’s available to us is available to them in an open notes format. And it works incredibly well, and patients are so happy, they’re willing to work with us as a cash practice. That’s one of the satisfaction factors is we take such good care of people, they’re happy to spend their hard-earned money with us. Which also leads to a great deal of joy. I’m not fighting insurance company every day to get paid. Instead, I’m satisfying the patient’s need and whatever their, their consumer requirements are, I’m meeting them or they wouldn’t continue to pay me.  

Erin – You’re also not waiting for reimbursement to pay for your medical supplies, your staff, your building, your electricity, all of the elements of your business that are needed in order for you to give good patient care. And so it’s nice to see a cash-based clinic do really well utilizing Eva. I also think there’s great capability in Eva to do well taking insurance as well because Eva, unlike other electronic health record systems actually fully incorporates the business needs into that system. Most electronic health record systems will have a little bit of business functionality here or there, but it doesn’t look at the full picture and actually connect the dots where Eva does so all the supplies you need, purchase orders, everything involved in creating a foundation or an environment to give the care and, and pay for it is there. And part of the reason why is, you know, we’ve incorporated the ability to have all of the correct medical coding directly associated with the patient interaction. Everything is included in one space. Easy to access, easy to build, easy for a patient to understand, easy for you to understand. And I think that that’s pretty revolutionary about Eva. I also think that Eva is unlike any other system because she is a healthcare system for independent medical providers, meaning she takes care of them. It’s not, it’s not like going to a large institution or a large EMR group where you’re going to engage with that larger institution and all that comes with it. When you work with Eva, you’re essentially working with an independent provider, a provider for a provider and their staff. And that’s the kind of care we give as a company. We replicate the care. We give clinically through our system. Eva.  

Dr J – You’re saying exact, the exact terminology that comes to mind. Though I don’t like it to jade people too much. It’s holistic. It takes in, it takes into account the first time the patient interacts with a practice, they ask, can you help me? Do you think? And then we can say to them very, very clearly, because they’ll have worked with Eva to get a very good interview done. We can look at that interview and tell ’em, no, we’re not a good fit, or, yes, we’re a good fit.  So, from the beginning, from the very first question, I’m not feeling well, can you help? Or, I need, I want, don’t want to die young, can you help? Then we can look at that and say, yes we can, or no, we cannot. From that moment on all the way through the interaction with the patient, laboratory work all the things that happen right up until the invoice is written and it’s paid, all of that is contained within Eva. Everything.  

Erin – Yeah, you’re right. And it’s what makes Eva beautiful. We know, the way I look at it with my developer background and design and interface in that is, other electronic health record systems that I’ve worked with are essentially these separate little cubes, and they’re connected via spider webs. So, if you’re seeing a patient and need to go check out their labs, you’re gonna go visit that cube. If you wanna look at their images, you’re gonna go look at that cube. If you wanna go to their chart for that visit, you’re gonna go to that cube, but you can’t access everything from the patient chart, from the instance you are there with them. And that’s incredibly problematic because if you need to resource stuff, what people are essentially doing is giant old copy and paste to find information or searching through large paragraphs of notes that have been copied and pasted and copied and pasted and then looking for labs and then trying to trend. Whereas with Eva, you go to the chart, you can trend lab results. It’s all in one spot. Because we knew being in the room with a patient, you know, that’s what you needed. You needed to be there as a provider and actually see everything right there. And I think that that’s my favorite part about Eva, is that it is 100% provider patient relationship focused. That’s what Eva is. She is your virtual assistant that supports the provider patient relationship. The last clinic I worked at, I worked with one of the biggest electronic health record systems, and this particular provider did a lot of procedures and then standard office time when we were doing procedures often provider would dictate, I would take notes and I would have to go and search for the diagnostic codes, every single time. I’d have to go rewrite the procedure note, find the template of it, rewrite it in, then make other notes while the procedure was going on, and it became such an arduous process that I would have to finish or the other nurse there would have to finish these notes before the provider could even access the notes. So what did that end up doing? You know? Cause you’re still running your day too. That created a little bit of a backup, but then the provider’s still seeing, patients still trying to keep up with notes and the backup just gets further and further and further. Did we optimize the system and make some improvements? Absolutely, yes. And you know, we streamlined as best as we could, but it was still impossible in that particular system to look at the patient intake forms, see the labs, trend them, get the full picture even before procedure to make sure, hey, does this person have a history of reoccurrent UTIs? Should we be mindful of that? There was no op opportunity to send like a pre-interview. How are you feeling? You, none of that was there. And so every single time you were recreating from scratch by referencing the old note, which had referenced another old note, you know, and that’s what I saw in the hospital too, using the largest electronic health record system and did, is that ethical charting? And is that ethical charting I mean, that’s up for debate and a whole other conversation of course, but really it’s what has to be done in order to get your work actually done so that a patient gets the care that they can. It gets approved, you get reimbursed so that you can continue to give care to other patients. And that kind of cyclical nature, just, it didn’t work. It really didn’t work. There is, you can actually look up reimbursement rates. It’s a federal database. It’s accessible to everybody. You can look it up. And one day I looked up the reimbursement rate of one of my most respected independent providers, and it was the first time that I could touch, just barely touch the feeling of what burnout meant, because you’re talking about a reimbursement rate that’s so low, you couldn’t even fund the staff there. And I’m not talking about all the staff, I’m talking about one single staff member. Part of why that reimbursement rate is so low, is because it’s incredibly hard to utilize a lot of these larger electronic health record systems to efficiently, quickly chart whether you’re taking insurance or not. And, and basically get the business and clinical side done with both of those areas simultaneously focused on the provider patient relationship. Eva does that. And that’s why I, again, begged to be the first clinic to use Eva and build her out for a different kind of provider patient experience.  

Dr J – Here’s deep dark confessions from my past, long before this was on the cusp of our very first artificial intelligence work. We were doing it. The way I used to do notes is I’d be busy and I would get really deep with a patient. I’d spend an hour and a half doing an interview. And so I’d write down notes on a legal pad, and then I would have to go back and do ’em. And sometimes I would forget. I would wind up, I don’t remember to do it that week or that, that even that month possibly, and have to go back to my piles of paper. Then I would’ve to reconstruct the visit from the beginning. So, I would say, wait a minute, what was their diagnosis? Okay, what would I normally do in that situation? So, then I would have to remember and rewrite the note, and it would take me literally hours and unbelievably duplicative effort. Like I’d already done thinking, I’d already done all the work, and now I had to do it all over again, because I had, I had delayed getting my notes done. And, because I’ve been in practice for 30 plus years, I’ve had my dance with the medical board. I’ve been investigated and looked at because I do alternative medicine. They always are interested in getting deep on that. And I worked in the emergency department in my early career, so I’ve, I’ve seen malpractice attorneys and I know how all of this works with documentation. And if you don’t do your documentation, you’re inviting disaster. But if you’re being asked to do documentation on a system that will kill you by burning you out and causing you to retire early or just absolutely lose your mind, which seems like a reach. But I think it’s really getting to that point where doctors are just so overwhelmed. We’ve been told by more than one person that you know, they’re, they’re completely out. They’re, they’re so done. They’re not gonna do anything. They’re, they’re not gonna look at any EMR, EHR. They’re just done. And there’s some language, colorful language that comes to that, sometimes, that we’re, you know, that we’re accustomed to. But I think that all in all you know, this is, this, this whole system is, is derived from a lot of hard work, a lot of really, really good success in the area of creating a data collection instrument that presents everything like in a wrapped up little bow. It’s like an Easter basket. Like on Easter morning when you’re a kid, it’s all done. All you have to do is open it up and everything’s there right in front of you and it, it’s all right there on the surface. All the data has been collected, all the discussions have been had, and then you can do the part that only clinician can do is apply that intuition and that clinical training and the background and experience and look at the patient and understand, okay, I’ve got all this data. It’s all right here. There’s not in separate cubes all over the world. It’s all right in front of you. All I have to is think about these, these small group of problems that are my venue, it is my area of expertise. How do I deal with the patient? I relate to them. I watch how they move, how they talk, how they respond to the interview questions when it gets even more detailed than Eva provides, and it’s consistently excellent. Consistently. And we’ve done over a hundred thousand tests with Eva. So, it’s not like it’s a new thing or that, or that the, the results are questionable or hard to understand. It’s like we’ve done it a long time. We’ve made a lot of modifications to make it more and more and more accurate until it’s a very accurate tool. I don’t have to second guess. Is it right or is it not? Right? So, with the patient for a few minutes, then I confirm all that data and make sure that it’s right. And then we, we march on in our collaborative way to create a really satisfying experience. So, I think that’s ultimately what I want people to walk away with is like, it can be satisfying, it can be really good. You can actually do notes and record keeping and it kind of feels like ringing the bell. Where you’re dinging I got it done. Woo. Not, oh my gosh, I finally finished and you drag yourself across the line and vomit in the recovery tent every night, when you’re done your records. That’s not good. It’s much better to grab that golden ring at the end of a, you know, carousel and, and have some fun with it, which is available with you. And it sounds kind of like it’s too exciting to be true, but it’s true. It’s how it works.  

Erin – I agree. It really works. I wanna end with the idea of collaborative and the nature of our company as well. And you know, I’ve gotten emails for people who are interested cause people who are interested in our product, like I deal with them directly. You know, we’re small and we are knit together pretty tightly, which I’m so grateful for. But I think the other thing we offer is most practices that I’ve worked with had don’t have the best relationship with their electronic health record company. And you know, the truth is, I’ll just be real honest, we can’t build a custom system perfectly for everyone meeting the adaptations they’ve made in their practice over time for the old way. Does that make sense. Yeah. I’d like to finish up with the idea of collaboration because I think it is a big foundation of our organizational culture. We are a collaborative, small tightly knit group, and I’m super thankful for that because it allows us to give service and create, actually create a relationship with the practices that we work with. That’s totally different than what they’re used to. Right. Most practices do not have a great relationship with their electronic health records systems, especially if they’re larger. I have met a few that I’ve worked with that are smaller and their customer service has been great. But did they change the way we gave care? Did they help actually focus the care on the provider and the patient? No. They sort of followed the standard operations that are happening, right now, which is billing centric, that’s what I like to call it. We’re trying to do something different, but in saying that, I, I wanna be clear and be honest because that’s the other thing that I love about our company culture, is that we are really honest about where we’re at and what we’re providing. We can’t build a custom system perfectly to meet the adaptations that practices have made over time for the old way, that’s not what we’re about. Does that make sense?  

Dr J – Yep. Perfectly. I totally understand. I think, yeah, we’ve, we’ve done that too. I think the the, the path to really joy in practicing it involves a whole lot of things. But if the technology is the obstacle, it’s so easy to fix. If you hate your job because you just won’t like seeing patients, well, there’s nothing we can do to help you. But if you’re, if you’re somebody who’s committed and has a calling to medicine we can help people. We, the idea is though, you can’t hold on to your buggy, whip and drive a car. You gotta, you gotta let go of some things and the things that you have to let go of are things that are just a headache anyway and everybody’s happy when their headache goes away. It’s just making that step where it’s like, oh my gosh, I’m gonna have to actually do something different in an area where they, I think everybody I know who I have spoken to has been burned by the EMR experience because it’s been going on for many years and there’s been many fails and I’ve experienced tons of ’em. And with Eva, we haven’t, anyone that we’ve worked with that’s a fail. We’re at a hundred percent. Everybody loves it. The relationships that our team has with each practice, it’s, it’s good. It’s all good. So our support’s excellent. Our customization is really, really good. The way that we train and support is it’s, it’s the same way that we treat patients. We want collaborate. It’s, it’s a shared process. And it’s driven by clinicians who care for people. I’m not trying to, you know, influence the bank account of a big company. I’m trying to influence the trend in medicine for the rest of the history of our, our environment, our world, our culture in the United States. Cause we’re, we’re, we’re off the rails. And there is, there is a required leadership and I think Eva’s part of that you know, there’s a million things going on that are amazing. People are curing cancer, they’re, you know, preventing surgical techniques that are unbelievably sophisticated. This is a simple thing. We’re actually enabling doctors to be able to do a great job understanding patients in enhancing their relationship to the point where that relationship heals, as well as the actual medicine that’s provided and where treatment and, and that big picture is where we’re heading with Eva and anybody I think who will give it a few moments to check out what Eva is will see it. It’s hard to mess.  

Erin – It’s almost like we are, it’s not almost. It is. We are the independent practice in are, even though we’re more than that.  

Dr J – You’re right. That’s a great way to put it.  

Erin – We’re there. That’s what we’re for this world. If you wanna go to a big hospital organization and kind of go through that, you know, if that’s your solution for your practice as a provider, awesome. Take that route. If you were looking for independent one-on-one care. And kind of smaller long-term relationships, that’s what we are, you know? And so there are people who wanna be in that other sphere and I go to that sphere and be a part of it and do the best that you can, cause there are those that do really well in it. But that’s what we are, that’s what I see ourselves as.  

Dr J – Well, it’s, I think that’s, I think that’s a brilliant topic for maybe our next podcast or the idea of, of the idea that. A relational quality to medicine be between the doctor and the patient is critical to good care. So it, it has been in the last, I don’t know, dozen, 20 years, whatever the idea of community-based care or group care, not personal care. It’s not one-on-one. It’s about maintaining the health of a community, which I have support. I think it’s a great idea, but not at the expense of the personal relationship between the provider and their patient. That patient has to know that their doctor is engaged with them, knows what their desires are, not possibly even knows to the depth of what’s the desire of, of their heart, what are they? They want to live to be a grandpa and they wanna be able to play with their little ones. What is their goal? And to know those things is the same thing that we want to do as an EHR company for the doctors that we’re working with. We wanna transpose that culture to client provider relationship where, and we do this all the time, by the way, we’re, we’re modifying the program constantly to adapt to what a doctor needs. It’s like if, if the doctor has a specific problem that we have not addressed then we address it and we put that on our, our big list and saying, okay, we’re gonna get to that when it’s, it’s appropriate. And, and we do make changes. We’re the most customizable program I’ve ever seen. I think it’d be really cool next time or the time after that to talk about the, the putting that culture into the business relationship between Eva and our our practices that we work with. I talked to a doctor the other night. We were chatting late in the night, and he said, I’m all alone out here, I’m all by myself and I feel like maybe with with Eva that I’m not gonna be quite so isolated in my goal to really do a great job for patients. And I’m thinking, wow, that’s like the, that’s like perfect. That’s, that’s where we want to be.  

Erin – Yes, totally. That’s where we wanna be. Well, it’s been awesome talking with you today. As always, Dr. J, thanks so much for your time, and I look forward to our next podcast where we discuss this topic a little further.  

Dr J – Okey doke. Have a good day 

Erin – Well, that’s it for today. Thanks for joining me on the Eva podcast. I’m Erin, your host, and I’ll see you next time.