An EHR Obsession

My Saturday morning walking partner asked me yesterday, “So when do you get to quit being an IT professional and go back to being a doctor?” Wow, good question.

In the not quite three weeks of this new form of documentation I have been consumed with trying to understand and make the EHR work for me. No longer do I have to consult a “superuser” every ten minutes with questions but every day I’m trying to figure out the most efficient way to care for people using this frustrating new tool. The “muscle memory” is beginning to kick in thank goodness, so time per patient is less. Now my frustrations are more with what seems to be a very inefficient system. I struggle to determine whether I am the problem or the EHR is. Most likely it’s a little of both. The term Mission Hostile User Experience coined by Scot Silverstein comes to mind. What is scary here is the potential for patient harm – between my distractibility due to the steep learning curve of the Allscripts system, the fact that no one has told us how to clean these “Toughbook” fomites that we carry from one patient exam room to the next, and the patient care error potential inherent in the software itself, these are the ever present worries that keeps me up at night.

On Thursday of this week, the EHR Steering Committee for my organization will meet and I will have the opportunity to present the go-live experience and make suggestions for improvement as other offices in the system go live. Throughout this process there has remained a sense of re-inventing the wheel, which seems odd considering that Allscripts EHR has been in existence for years, having gone public in 1999.

At any rate this blog is obsessed with EHR right now–but the essential question remains. When do I get to go back to taking care of patients?

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Patient response to Electronic Records

Amazingly my patients have had a very patient response to the introduction of EHR (Electronic Health Records) to our office. They sit and watch me type and curse with an air of amusement and calm. More calm than I am feeling.

Yesterday began our third week of EHR. Muscle memory has kicked in and I saw 15 patients without running too far behind. Seeing 20ish patients daily again is starting to look feasible. Someone walking into my office no longer has to look over mounds of paperwork to see me. My only concern is whether my employers will cease to understand how much work I do if they can no longer see the physical evidence of it.

On an up note, there will soon be a couch in the area where the credenza is now. Since my colleagues warn me that it will continue to take longer to finish my charts it seems reasonable to have a comfortable place to do so. The main purpose of the credenza was to support the hundreds of charts I needed access to on a daily basis. The staff is very supportive of the change as well (wonder why…).

Many patients have followed me over the 25 years I’ve been in practice. While little has been different in the exam room until now, there have been lots of other changes–two previous locations, private practice to employed doctor, hospitalists, urgent care centers, and oppressive insurance controls to name a few. For the first time in two weeks, I was able to gauge patient reactions to this new-fangled way of documenting. Prior to yesterday I was too bogged down with clicking boxes, losing screens, figuring out where to put a new symptom the patient just threw at me, finding templates and vital signs and generally being absorbed by the Allscripts system to observe my patients (and please don’t make me worry about what I may have missed in patient care over the last two weeks while I followed this steep learning curve).

Now I carry this new contraption in the room:

My younger patients hardly notice it. They would not have commented had I not explained its newness and why it was taking a little longer to enter information than usual. Older folks regarded it with expressions ranging from dismay to perplexity. Most of them commented before I did.

  • “Do you like it?” 
  • “Do you think it will ultimately speed you up or slow you down?” 
  • “How hard is it?”
  • “Did Baptist (my employer) force you to do that?”
  • “What happens when the system goes down?” (I wonder about this one myself)
No one seemed particularly surprised or overly worried about my use of a computer to document their visit. They all seemed impressed when I stood up and said that their prescriptions were already at the pharmacy. 
At the end of the day what most impressed and humbled me was the sense that within their acceptance of this new device was a trust that regardless of the way I document their care, it would still be delivered in a way helpful to them.
At the end of the day, that’s what it’s all about, isn’t it?
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Finding a Better Way Down the Electronic Pathway

Clicking on a link from Twitter this morning, I read an article about how distracting email is in the workplace. That got me to thinking so I googled “digital distractions” and found this amusing infographic by David McCandless

http://www.informationisbeautiful.net/visualizations/the-hierarchy-of-digital-distractions/

It’s hard to see on my blog but my favorite part of the visualization are the words “partner shuts the lid of laptop on your fingers” encircling the star at the top. Sometimes I want to do the same to myself. One of the more physically painful manifestations of “too much computer” happened last week when my eyes began to sting, burn and water after going live with electronic medical records. Adding six more hours a day looking at the screen was some sort of ocular last straw.

In the risk vs. benefit analysis of computer use, where is the balance? Wednesday night I participated in an #mHealth twitter chat on the topic of “access to medical literature“. This was primarily about researching tools and how to find articles but because of the chat, it occurred to me just how often I utilize Twitter to access current medical information. Most of my contacts on Twitter are involved in mobile health or patient care so lots of very relevant information is tweeted and I click on the links. From genomes to medical policy to the latest treatments for atrial fibrillation, it all comes across the feed and when I have a moment I click, read or save and go on with life.

It’s still unclear to me how to balance my time, choose wisely with my clicks and still fill my life with all the other important moments. If someone else has found a better way down the electronic pathway, please let me know.

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An Electronic Health Record misAdventure

We thought we were ready. We had all our training. The staff was pumped. The doctors were apprehensive but willing. Tuesday morning “GO LIVE” began. Fortunately the hardware folks just happened to be in the office installing our dual monitors, so there were two techs present when none of our medical assistants (MAs) could access their tablets. Uh oh…

Shortly into the day our office manager discovered that the stand-alone electronic prescribing software we’d been using for years had been turned off since Friday and prescriptions sent electronically since then had never made it to their destinations. Patients were calling. They weren’t happy. And we had no way of knowing who they were because our workflow is to fill the prescriptions, document in the chart and file. Uh oh…

Meanwhile, my MA was still unable to use her laptop to triage my first patient. I was waiting…Dr. K had seen a patient, documented most of her note but she could not put in the plan for some reason. This was a problem that went on all day until it was determined that her ‘profile’ was corrupted. IT promised a fix by the next day. Uh oh…

Remember being told to “save, save, save”? Dr. I, not big on computers to start with, was humming along only to find out that one of her electronic notes, on a complicated patient, had vanished into the ether due to a Citrix glitch, never to be found again. She was nearly in tears. Uh oh…

Finally, my MA had a patient ready for me to see. Only an hour behind. It was a young man, a new patient in for what the scheduling staff was told was an uncomplicated physical. I remember being told that this patient was perfect for the first day on EHR “He’s young and healthy, a great start to using the Health Maintenance Template”. Except that he was drinking a pint of bourbon daily with a blood pressure through the roof, a urination issue, chest pain and was anxiously depressed. Uh oh…

It is very difficult to have one’s attention divided by electronics when it needs to be concentrating on a real person’s medical issues. If I had to grade myself with how well that first patient was treated by me, it would be close to failing. It felt like a return to medical school–working blind, feeling incompetent, trying to speak two different languages at once (electronic and paper) and never quite sure anything was being done well.

Rumor has it our skills will improve over the next year. My hope, as one of the first primary care offices to go live in our organization, the technical support staff and the doctors can help other offices begin this journey with a refined send off.

This is a hospital “go live” but still hilariously hit close to home:

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