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:

 

HISTORY
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
Syncope
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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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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A Call to Action from HiMSS

For those of you who are not geeks, or not healthcare geeks, I have spent the last week in Chicago at the biggest HIT (Health IT) “geek-out” in the world. Some 42,000+ people gathered in Chicago for the annual HiMSS (Health Information Management Systems Society) meeting. It is truly an overwhelming experience. On the first full day of the conference I got lost twice. Not an IMG_8195auspicious start.
As a member of the Connected Patient Committee for HiMMS, I participated in the Patient Engagement Symposium which brought together individuals passionate about using HIT to improve health in patients and communities. ONC representative Lana Moriarty (Office of the National Coordinator) spoke to the government’s goals along these lines. E-patient Dave Bronkart, a celebrity among patients passionate to change our healthcare system into a patient-centered and patient-empowered one,  came to watch  his personal physician discuss changing care models and shared decision making. Amy Gleason of CareSync presented the patient’s viewpoint when it comes to dealing with multiple portals. The highlight of the day was a call to action, voiced below in the video by Regina Holliday, well-known advocate for patient access to medical records. The “call” was made by Dr. Farzad Mostashari, former National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services. On the day before the conference began, CMS (Center for Medicare Services) proposed dropping the Meaningful Use (MU) requirement in Stage 2 (of three) from 5% of patients being able to view, download or transmit their medical records to ONE patient. Most individuals in the patient advocacy arena feel this proposed change sends a message to health systems and providers that patient access to their records is either no longer a priority or special interests have pushed this change of heart. This seems particularly odd in an environment of increased encouragement of patient involvement in their own healthcare.  NoMUwithoutMEDr. Farzad, e-patient Dave, Ms. Holliday, and myself are just a few of the many individuals who think this is the wrong message to send. As a consequence a Day of DataIndependence on July 4 has been declared, and patients are asked to request electronic access to their medical records by calling their physicians and hospitals and asking for their medical records in electronic format.
If access to your medical records, or your family’s medical records, is important to you (and it certainly should be!) watch this space for more information in the next few weeks.  For information from the Society for Participatory Medicine regarding this issue, follow this link: No MU without ME.

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An IT Transformation

Years ago, when I started working at my system as an employed physician, my perception of the IT department wasn’t very flattering. My first interaction occurred when we wanted to download the patient demographics from my billing company’s software to theirs. The program used was a common one on the market but the answer was a resounding no. As a geek I know a little about databases, so I knew it could be done. When asked “why not” my IT deptpartner and I were told that IT was concerned about getting a virus. What?!?! Seriously? So my staff started from zero inputting data for a few thousand patients. What a waste of their time.

My next aggravation was software upgrades done at convenient hours–for IT. The idea of taking down a system during regular working hours at any large corporation was ludicrous but at a hospital? When discussing that the “tail seemed to wag the dog” in our system, administrator types would just nod sadly. When our outpatient EHR was being chosen I hoped to be on the physician committee to help. No such luck. Partly because there was no such committee. Seriously?

In early 2012 my geekiness finally became obvious to administration. Someone decided I would make a good EHR Physician Champion. As Allscripts Enterprise was implemented I threw myself into the job. The program and the process was frustrating in many ways but slowly I met a lot of people in the IT department. The first surprising thing was how excited analysts were to have a doctor willing to talk to them. I’d get email questions about how best to configure things to fit physician workflow. One day it hit me. The irritation doctors had often matched the analysts’ angst when making EHR configurations for patient care matters. Sometimes it was as simple as not having access to a doctor to ask the question.

It is clear that lack of usability in EHR systems has to do with inadequate end-user input.[1,2] The good news is that there is a refreshing change in attitude. As more physicians move into leadership positions, IT leaders appear delighted to partner with us to improve patient care.  Another silo is torn down to serve our patients better. Life as a doctor just got a little bit lighter. And maybe that’s true for the software analysts and project directors over in the IT building who more and more are recognized as being an important part of the healthcare team.

  1. 1. EHR design flaws causing doctors to revert to paper. Dolan, Pam. amednews.com 4/8/13  http://www.amednews.com/article/20130408/business/130409961/6/
  2. 2. What causes physicians to become dissatisfied with EHRs? Murphy Ph.D, Kyle. EHRIntelligence.com 12/13/2013 http://ehrintelligence.com/2013/12/03/what-causes-physician-to-become-dissatisfied-with-ehrs/

 

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The Irony of a Paper TOC Document in an EHR

Over one year ago my office implemented Allscripts Enterprise EHR (Electronic Health Record). I’ve not done a note on paper since. Last week, a “Transition of Care” (TOC) document was placed on my desk with a sticky note stating: “Dr. Nieder please fill out this form so we can bill a 99496 for your visit with Mrs. Jones yesterday”. I pick up two sheets of paper with multiple questions including: 

  • Discharge Medications: (list)
  • Present Medications: (list)
  • Diagnostic tests reviewed/disposition (list)
  • Disease/illness education (discussion documentation)
  • Home health/community services discussion/referrals: (list)
  • Establishment or re-establishment of referral orders for community resources: (list)
  • Discussion with other health care providers: (list)
  • Assessment and support of treatment regimen adherence: (discussion documentation)
  • Appointments coordinated with: (list)
  • Education for self-management, independent living and activities of daily living: (discussion documentation)
Please remember, I am now on an EHR. So I am expected to document in the EHR and THEN fill out these forms. I have no discharge summary yet from the hospital. It may be ready but no one sent it to me and since our hospital is not sync’ed with our ambulatory clinics it didn’t seamlessly flow into my patient’s chart when she was discharged. When I finally do get it, there is no mention of any referrals given other than with the surgeon she saw in the hospital and me. The discharge medications state “resume pre-admission meds”. In order for me to list what tests she had and make sure they are normal I have to return to the hospital portal and look them all up. Some of them have already been scanned into the EHR. I have no idea if there were other referrals made but I doubt it. She had a very straight-forward admission for a small bowel obstruction. She declined to keep the surgeon’s appointment since they gave her instructions in her care in the hospital. I concurred about that. She could call them if she needed them. The women is a healthy 65-year-old who still works part-time as an accountant. She travels a lot. 

This TOC visit is paid at a much higher rate than other visits IF the patient does not return to the hospital in the next 30 days. Hence, we hold the billing until that time. 

My understanding of the purpose of this new code is to improve the CO-ORDINATION of care as the patient transitions from the hospital to home. Coordination would imply that there are other individuals involved in giving the patient care and thus we should have improved COMMUNICATION

between us. However, at least in my institution, my staff and I bear the brunt of gathering information (which is what we normally do anyway, so I guess it’s nice because now we get paid for it). 


At what point will it become incumbent upon the hospital, who I work for, to send me the necessary information for treating the patient now that he/she is home again? How does it follow that improving care means the primary care doctor fills out even MORE FORMS ultimately reducing the time spent with the patient? At what point does the operability of two disparate systems (office EHR and hospital EHR) talk to each other and the information I need is already in the EHR? Why isn’t all the information the patient needs sent home with her and she is told to bring that with her to her primary care doctor’s visit which, oh by the way, should be done within two weeks? Why aren’t all appointment made before she walks out the door? 

The form will not keep the patient out of the hospital. Communication will keep the patient out of the hospital. True coordination of care might keep the patient out of the hospital. More busy work for the patient’s primary care doctor will not. Since the order of the day is using hospitalists (a discussion on that is a post for another day) it is imperative that we improve our communication systems at the time of discharge and before the patient is seen again in the primary care office. Systems must stop thinking that one more form is going to save the patient. Especially another form on my back.


This post’s ending was rewritten on 10-10-2013 to take into account the multi-faceted reasons for the form.

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Be Careful What You Wish For

Physician-to-physician communication has become an increasingly difficult problem and its lack has worsened the fragmentation of healthcare today[1]. The challenge is complicated by many things:

  • Physicians lack the time to call colleagues about patients when their income is patient volume-based 
  • Fewer opportunities for direct physician contact, i.e. the doctor’s lounge
  • EHR systems cannot talk to each other
  • Patients don’t always tell their physicians about other doctors taking care of them
  • Printed EHR records are so full of verbiage that important findings are missed by the doctors trying to scan pages of unimportant documentation
  • Patients rarely carry their health histories with them in any format outside of memory
Another problem, at least in the healthcare system where I work, is the lack of a centralized area where physicians can come together to find community specific information. Blast emails are sent to doctors whose boxes are already full of “junk”, making it difficult to separate the wheat from the chaff. Recognizing this problem I recently approached the IT department at my institution. 

It was gratifying to me that they not only understood the issue, but were excited about assisting in a solution. My vision is to create a Physician Community where providers can go to find answers and communicate in a secure environment about any number of issues–problems with EHR, announcements, medical directors’ updates, calendars with CME and other dates of interest, blogs, CME, vlogs, links to outside trustworthy medical sites, and a place to crowdsource patient or system problems. IT gave me access to build such a community in a Sharepoint environment. 

Of course in addition to the problem of building the environment and populating it with what the doctors need, is getting them to use it. I feel certain that “If you build it they will come” does not apply in this situation. I envision needing to enlist lots of assistance from the President and CMO of the system down to the office managers and EHR superusers. 

I’m a firm believer that Social Media is the most important revolution in patient care today. Effective electronic communication between physician is part of that movement. But today, as I’m reading Sharepoint for Dummies, I can’t help but wonder–what was I thinking and can this make a difference? 

References:
1. Shannon MD MPH, Shannon. peg.org. January/February 2012. http://www.perfectserve.com/resources/docs/ACPE-PhysicianCommunication.pdf
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The Catch-22 of the Physician Champion Role

Yes, I’m a geek. When my girls were in high school, their friends were amazed that they received texts from their mother. One daughter has commented on Facebook that her mother is more tech-savvy than she is. At the beginning of 2012 my interest in the healthcare benefits of social media was born and I began blogging. I investigated and use LinkedIn, Twitter and Google+ while remaining attentive to Pinterest, AboutMe, Doximity, Instagram and others. So when my employer offered me the position of EHR Physician Champion for our physician group a couple of months ago, I took on the challenge. And challenge is the operative word.

Presently there are about 25 physicians in our 180+ multi-specialty group “live” (using electronic records). In a meeting specifically called to discuss “Provider Go-Lives”, three individuals tasked with implementing EHR turned to me and said, “So Dr. Nieder, how can we encourage doctors who are not embracing EHR to do so.” Hmmm….good question.

Let me preface these remarks by stating that our administrators have tried everything in their well-researched knowledge base to make this transition work. As we move forward improvements are made with every new Go Live. My immediate response was two-fold:

  1. In training, don’t give physicians the impression that using an EHR is using a paper chart in electronic form. It is an entirely new way to document and, unfortunately, the learning curve resembles third year medical school with IT support instead of attendings. It is every bit as daunting. 
  2. Encourage the doctors to shadow with someone already successfully using the system. 
The next question was harder. “What can we do to push the physicians who are balking?” Ah, therein lies the rub. Of course I recognize that the question was also my responsibility in the role of Physician Champion. To answer it, I was going to have to do some thinking. There are many reasons doctors give for not wanting to use EHR as posts by Palmd, HealthcareTechReview, MITTechnologyReview, and others attest but the biggest one in my system is that it slows down physicians whose salaries are based on productivity. 

My understanding of the value of EHR is simple enough–more legible notes, better population care using “big data“, enhanced patient care using clinical decision support tools, improved documentation to increase reimbursement, establishment of direct patient communication through portals, healthcare savings by reducing duplicate test ordering, and improved communication between providers in continuity of care. Even though our present system is poised to realize all these goals, the only one it is capable of performing at this very moment is legibility. So how can I convince physicians to use a tool that is going to slow them down (i.e. reduce their pay) and doesn’t yet have the necessary functionality to improve patient care?

As a geek, the EHR experience has me torn between two emotions: incredulity at its lack of usability  and that sinking sensation I remember from the late 80’s when the software rarely did what it was advertised to and crashed all too frequently, freezing the computer and forcing the user to restart both the software and often the entire system. The promise was there but the reality was long in coming. So too is today’s EHR. 
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