The Epic Circus Winds Down

For the last two weeks I’ve had my head down jumping through hoops, working hard to personalize Epic so my

 JEFF HEINZ/The Globe Gazette

JEFF HEINZ/The Globe Gazette

documentation is accurate, thoughtful and describes the patient’s story to the reader. We’ve had the usual glitches with hardware and software but the major problems have eased. I still don’t like the “dumb” thin clients which lock me out of the patient’s chart and have me walking up and down the hallway in order to close the software in one location so I can put orders in or finish my note in another. It is a terrific waste of time.

So what do I like about Epic?

  • -The interface is pleasant to the eye.
  • -The ability to make physician-specific templates of things I say to patients and staff repetitively on-the-fly, as I see patients.
  • -The big screen format.
  • -The ability to communicate with patients via the MyChart portal in a more robust manner.
  • -Releasing patient notes to them in the portal (although it sure would be nice to have a default button so I wouldn’t have to choose that option every time).
  • -Having an online community on the Epic site to discuss software “fixes”.
  • -In March, all of my system’s employed physicians, Immediate Care facilities, hospitals and ERs in my area will be onboard. Since the chart is patient centric, I’ll be able to see what’s going on in those facilities.
  • -Some true intraoperability–I can access patient information from any other Epic source in the country, including across town. This is huge and has already impacted patient care in a positive way.
  • -Having support in Verona, WI (home to EpicCare) with the expertise and desire to help you.

What I don’t like about Epic:

  • -Everything we do with patients is an “encounter”. I have to open one to write an order, document a telephone conversation, etc. If I open one and change my mind, I still have to sign the darn thing instead of just cancelling out of the encounter.
  • -It is too “clicky”. Things that should be accomplished in one click takes multiple. Thank goodness there are plenty of keyboard shortcuts but for individuals that aren’t used to using them, that is of little help.
  • -The lack of a Verona-based Epic expert in our office the first day of GoLive. We spent so much time figuring out simple things that someone with more training and experience could have told us in seconds.
  • -My work environment is not designed well. I have to strain my neck to keep eye contact with patients, or turn the computer away from them. I’ve got to work on this. There has to be a better way.
  • -The most annoying thing, and a big backward step for me, is the inability to get email notifications when a patient messages me on the MyChart Portal. Since 2013 my patients have had answers to their medical questions at odd hours of the night or on weekends. That is not possible with MyChart, although I guess I can get a one time notification in the evening if someone has sent me a message IF my system Leadership approves (and why would they not OK that?). This is definitely a step backwards, and in a time when patient engagement is considered so vital, it seems odd that the arguably “best in Klas” EHR doesn’t have that functionality.

Oh, and did I mention how much I dislike the thin clients?

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GO LIVE, Day One

All the patients in my office who were inconvenienced yesterday deserve my thanks. They endured long processing times and our somewhat distracted visits with grace and good humor. They should be rewarded, as some of them waited over an hour to see me and all of them spent much longer in my presence than usual and without my utmost attention.

The morning began with a tweet from one of my twitter friends, based on my previous blog post:

Screenshot 2015-10-28 18.31.10

It was rainy, dark and cold but on entering the office the bustle of extra people made it cheery. That seemed an auspicious start. Administration cut our patient schedules by half, much improved from our last implementation when lessened schedules were frowned upon and the physicians had to worry about their paychecks. This decision has created a learning environment.

My colleague was an incredibly good sport, despite the fact that she was given less than adequate support because, for some reason, there were no Epic personnel in the clinical area of our office. The trainers are as newly minted as we are. For geeky me, this was a puzzle to be solved and between our clinical superuser, my personal trainer (who is actually an administrator superuser) and myself, we could usually ferret out how to do something. Of course we were never entirely sure we’d made the right choice and there was the frustration that the same problem would have been solved in 30 seconds with an Epic specialist to show us. Toward the end of the day we had Meg from Medsys who shortened my learning time significantly and I was able to begin the personalization process which will make documentation faster and easier.

We had significant hardware/Citrix challenges including timeouts, frozen screens and difficulty signing in. The front desk personnel were registering patients in an impressive timely manner until they had a  motor vehicle insurance issue. Things slowed down to a crawl. However, the front staff was engaged and not overly stressed. They commented that their “on the job” training was many times improved over the classroom training.

The hardest thing for me is the flow of charting. Learning to document an encounter instead of a note makes sense in the electronic record but it’s been exasperating to tie the visit together because elements are in many places of the encounter–did I do all of the physical exam? Where is the physical exam? Did I renew the meds? Where are the meds? Did I order labs? Where are the labs? Which labs did I just order? How do I know I’m finished? It is no longer a linear process. The jury is out on that–there is no summary screen to review to ensure I’ve covered everything. I feel as if I’ve created a documentary mosaic.

The implementation staff responded quickly to our complaints and concerns, working hard to find answers to our questions and being honest with us. I applaud them.

My first impression after day one is that Epic is not as intuitive as it should be. It has many ways to accomplish the same thing which is a strength as well as a handicap. It will help me document faster than my previous EHR and it has the capacity to remind me of health maintenance such as mammograms and vaccines that are due on patients. It does not yet have clinical support tools embedded in the software and I look forward to that. I don’t love it, but I will probably like it some day and it’s already a huge improvement on my previous system.

It’s no circus but that’s probably a good thing. I really don’t like clowns.

Next week, next update.

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Training, Take Two

Second day of Epic training went well. We were taught Inbox processing and how to interact with the patient portal. This was miles more straight forward than documenting a patient encounter. The following morning was “personalization lab” where things that are done every day can be made into macro-like phrases or entire notes, to make documenting faster. Unfortunately on arriving for my training, I couldn’t get into the live environment. For an hour and a half. Our trainer kept calling the IT security folks who would  say “She should be able to get in now”. Nope. After one and a half years of preparation for this moment, they waited until the day before to give us access. Seriously? Since anything that can go wrong does, why was that felt to be a good idea?

The afternoon was spent in a dress rehearsal. Thank GOODNESS we did this before seeing live patients. The hardware, which had been tested with two previous technical dress rehearsals, did not work as expected. Multiple issues ensued and I have minimal hopes that GoLive will not see similar problems crop up. It took up to two minutes for the Epic software to load on our thin clients . In order for us to get faster loads we had to get rid of the ability to open up our previous software in the exam rooms. This means, in order to see the patient’s old charting, I will have to carry another piece of hardware or leave the room. Not efficient, especially since there is also trouble with the database with all our scanned information. Next we discovered that logging into the thin client took us to our patient schedule instead of straight into the patient’s chart. Not only an efficiency problem, but a compliance issue since a patient could theoretically see othecow-245690_1280r patients’ names and reason for visit.

We had software issues as well but those were minimal. Of course with no trainers to help the end users, we could accomplish only the minimal tasks our eight hours of training gave us. Go Live should be interesting–my associate has armed us with dark chocolate M&Ms (since alcohol would be frowned upon) and is bringing a cowbell to make sure she has no trouble getting the trainers’ attention.

Cowbells, chocolate and a shiny EHR software right out of the box. What could go wrong?


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Will My Charting Be Epic?

“Ambulatory 100” went well. The trainer, Joel, was knowledgable and went through a reasonably accurate episode of care with a patient. I think I can write an adequate note today IF the problem was not very complicated and IF I had thirty minutes to do it.

Over the weekend we will be able to access a “playground” and get a better idea of what the program looks like and how it functions. A physician acquaintance, who uses both Epic and our present EHR in her daily work, assures me that life will get better and patient care improve on Epic. This is encouraging.

Abundantly clear, even in early interaction with the program, is how personalization can make workflow better in the creation of a note. Will this improve diagnostic thinking over my present system? Hope springs eternal. Dropping charges looks like a breeze (there’s a surprise) especially with ICD10. Concern about how well the patient’s story will be documented lingers. When I’ve seen notes from ERs in other Epic systems, the narrative is often poorly done. We are told this is due to  the way the system is set up rather than the fault of the EHR.

One of my present EHR’s big downfalls is how long it takes to process patient-related information outside of the note itself. Referral letters, lab results, r320px-Lion_tamer_(LOC_pga.03749)adiology exams and other testing take forever to “verify” that I have looked at them. It’s a monumental task for a primary care physician , frequently feeling as if there are too many cats in the cage full of hoops to jump through. Hopefully we will cover this Wednesday in Ambulatory 200.

The circus is in town. Is there a lion tamer?

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A Go Live of EPIC Proportions

circus-653851_1920In exactly two weeks my office will “GO LIVE” with Epic EHR (Electronic Health Record) 2015. This is a much anticipated systemwide move from our present EHR software and has been heralded with a circus analogy, a horde of analysts and other HIT experts, inconceivable amounts of money, two years of planning and general dis-ease among the doctors who are about to experience the change (see what I did there?). We are going live before the rest of our statewide system and I give credit to my associate, Dr. Diana Irvin, for not killing me when she learned that we would be one of the two pilot offices. Of course there is still time for her to rethink that…

We begin “for real” training this morning, the first of three sessions. I participated in pilot training three weeks ago. This was poorly done and now worries me as to how today will go. For a software product that has been around for so long, it was astonishing to me that the pilot was so badly organized. Epic disavowed any responsibility for that in the voice of its representative at our last GLRA (Go Live Readiness Assessment) meeting. Fortunately I have every confidence in our Medsys consultant and Chief Medical Officer (CMO) to make the training more meaningful and efficient for physicians. They have impressed me over the last two years by having an understanding of how to make things work better for the doctors in matters of our developing EHR.

As a Physician Champion for this effort, the most meaningful training I’ve experienced occurred last week when I sat down with three IT analysts and went through a couple of scenarios specific to my workflow. After almost a year of Epic video examples I could finally see the power of the software. It’s clear that it needs a lot of personalization to make it hum, but I caught a glimpse of possibility. As a geek that makes me excited. As a physician, I don’t know. How much will this tool speed up my ability to see patients while amassing helpful data and improve patient care? Will I finally get home before 7 pm every night I work? My colleagues just want to take care of patients. They are not interested in software and most of them are not digital natives. How much can I help my associates in my role as Physician Champion, to speed up the tool? We’ll see.

I hope the circus analogy doesn’t make clowns of us all.

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When the Narrative Isn’t

With the advent of the AHR I frequently get notes from referring physicians are ERs that look like this:


Chief Complaint
Patient presents with
• Dizziness
• Syncope
Patient states he passed out x3 prior to coming to the ED. Per patient, I fainted three times at home. The last time my wife called an ambulance and they brought me here
Patient is a 32 yo male presenting with: syncope
History provided by: Patient
Language interpreter: no
Episode history: Multiple
Most recent episode: Today (Patient states he fainted x3 this morning)
Duration: 20 seconds
Timing: Intermittent
Progression: Worsening
Chronicity: exertion and standing up
Witnessed: yes
Relieved by: Lying down
Worsened by: Nothing tried
Associated symptoms: Difficulty breathing and Dizziness
Risk Factors: coronary artery disease

I find templated text difficult to read. Does the version above tell the patient’s story?  Since I’m not a computer, it’s easier for me to encompass the story when it’s written in a true narrative form:

     Patient presents to the emergency room following three distinct episodes of fainting. The first one occurred in bed while he was lying down. His wife noticed he had stopped talking, shook him and he seem to be back to normal. The next episode occurred when he was walking into the bathroom and his wife heard him fall. The final episode occurred on the stairs. Each episode was only a few seconds  in time and there was no loss of bowel or bladder function with them. He did not appear confused following the spells. All episodes occurred within the space of about 30 minutes. EMS was called and they did an EKG and were concerned that he might be having a heart attack (patient has a left bundle branch block that is not new). He was mildly short of breath and a little dizzy prior to the third episode. He denies chest pain. Nothing clearly made it better or worse. He has no prior history of fainting or passing out. He does have a prior history of heart stents for coronary artery disease.

Perhaps I’m old-fashioned. Maybe the templated writing is just as effective, or maybe more so when understanding what happened to the patient. I’d love to get your opinion. Please write in the comments below.


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Brief Observation on “Med Reconciliation”

Patient is seen by her nephrologist and there is documentation in her Plan of Treatment: AVOID ALL NSAIDs. The physician never noticed in the med list that the patient is taking an NSAID (and has been for years). The only reason I picked up on it was because the patient told me she hadn’t been able to get her Celebrex approved by insurance so the orthopedist changed her to meloxicam. Having read the nephrologist’s note right before the patient came in, we have the following exchange:

Me:”But you’re not supposed to take an NSAID like meloxicam”

Patient: “I’ve been taking celebrex for years. Nobody told me to stop”

Me: “OK, I’m telling you to stop”

Patient: “So I can use advil every once in a while for pain? Tylenol doesn’t help”

We have an extended conversation about what NSAIDs are.

What IS it about EHRs that make straight-forward information difficult to see?



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Thoughts on Turning 60–What’s with that?

Sixty is a formidable number. Different from 30, 40, 50. One of those “decade” numbers that stops you in your tracks. Fifty was a bit intimidating but ultimately the approach and the finish of 50 turned out not to be a big deal. However, I’ve been thinking about 60 for a year now and I suspect I’m going to continue to ponder it for a while throughout the next several months. It is the top of some distant hill that I’ve reached, huffing and puffing along. Turning to look behind there are so many great memories but looking forward seems mirkier than other hills climbed in the past. Darker and a little frightening.

Why is that? Mortality is closer. Fears of morbidity arise. I’m a little stiffer and a little heavier than I’ve ever been. Getting pounds off is so much harder than it used to be and I’m less willing to put in the work to do so. What’s with that? I’ve always been a very goal-directed individual and now I find myself wanting to sit quietly, enjoy the moments and draw more often than choosing the next thing to accomplish. What’s with that?

I considered getting a master’s in something—Informatics being the most likely candidate. All my peers seem to be doing that—no longer is “just” an MD satisfactory. You need a Master’s in something—an MBA or an MPH (public health) or Informatics. So I did some research on pursuing that. I enjoy learning, why not? Well primarily because I wouldn’t have time to do any of the other things I am enjoying—traveling, drawing, spending time with friends and family. And what would a master’s get me—another frame on the wall and an opportunity to work harder? What’s with that?


The drive to become something else is gone. Been there, done that–mother, doctor, wife, blogger, geek–check, check, check, check, check. My children are grown and successful, my marriage is happy, my career cemented. After years of ambitious productive activity it dawns on me–finally, I can do what I enjoy doing—drawing, writing, seeing patients, tinkering with Apple products–and saying no to ambition.


At 60, I get to choose just being better at the things I do now. I can quit dabbling.


And I am so OK with that.


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Why Doctors Call It Meaningless Use

In the last week I have received three documents from hospitals that illustrate what physicians find so frustrating about the MU (Meaningful Use) program.

Example #1: Patient’s wife calls me for an appointment regarding three episodes of passing out. On obtaining the emergency room records there is no mention that the patient lost consciousness. In fact, there is no story whatsoever regarding the patient’s presentation or symptoms. All that is in the document is lab values. I can tell that the ER physician evaluated the patient for a heart attack which is not a typical workup for passing out.

Example #2: Patient presented to the emergency room with shortness of breath. As far as I can tell she was given four nebulizers (breathing treatments) and sent home with no new medications or orders. What?

Example #3: This was a discharge summary following hospitalization. It lists the patient’s allergies, lab reports, radiology tests and medications but yet again, I don’t have the patient’s story or the other physicians’ thoughts on how treatment progressed and how the patient did, in other words, the narrative that physicians use to communicate with other physicians is completely missing.

After receiving those documents early in the week two more were faxed. Thankfully, these give me a Paul Harvey “rest of the story”.  So how is this meaningful?  The information I need to care for my patients was not contained in the first documents whose sole use is to fulfill meaningful use requirements. I am forced to look at two documents when one would not only suffice but actually be helpful. This wastes my time in an already time-stressed schedule. It is neither meaningful nor useful.

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