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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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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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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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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Let the Patient Write The Referral Letter

On the portal this morning I received a great note from a patient. He’d seen two specialists and was checking in to tell me what had happened in those visits. His summaries were succinct, tell me exactly what I needed to know about what transpired. It took me about a minute to read them. Since the advent of EHR-generated referral letters I’m unsure that I’ve read a better referral note.

After reading it, I knew the assessment of the problem, the treatment plan and when he would be seeing them back. I did NOT receive one to tenMedical_Software_Logo,_by_Harry_Gouvas pages of past medical and family history that I already knew. I did NOT receive a list of the medications he walked in the door on, which I already know. I did NOT receive his insurance information, which I already have. Etcetera.

When will EHR vendors be able to extract information and template a referral note that only contains what I need and not streams of unnecessary information that gets in the way of my being able to read what I do need to know? When will physicians help the IT department cut out all the useless crap in those letters? If they’d like the name of my patient to help them, please contact me. I’m sure we can work something out.

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A Better Idea for the Post-Visit Phone Call

256px-Google_voice.svgThis morning an article caught my eye and then my imagination: The Dreaded Post-Visit Call. It describes a patient who becomes worried after getting a post-doctor-visit phone call. She doesn’t understand its purpose and calls her physician thinking something is terribly wrong. Apparently his healthcare system employs individuals to make these calls after every doctor visit to ensure “patient satisfaction” (THAT PHRASE!). At any rate, it got me thinking about the future of calls like this.

It is not outside of reality to envision other entities making post-visit calls.  The doctor’s employer can use the data to determine bonuses. This call could be followed by a post-visit call from the patient’s insurer. These calls could collect data to be used to determine if an insurance company will continue to keep a particular physician in their network based on some sort of satisfaction algorithm. It’s not hard to imagine CMS (Center for Medicare Services) getting on board with this as well as private insurers. Maybe the federal government could get further involved to create a Patient Satisfaction Data Bank. That could be the patient’s third call. And since nothing seems to be private anymore, Healthgrades could make a post-visit call when a patient tweets or posts to Facebook that they were in Dr. Jone’s office. This would increase the number of individuals rating doctors and isn’t that a good thing? Or is it…Why Rating Your Doctor is Bad for Your Health?

Let’s get more anonymous individuals involved in patient’s care, ticking off boxes for corporate data gathering. Or maybe, healthcare systems could train and employ health coaches who do know the patient. Getting a phone call from someone who really cares if you understood what was said during the visit and that you know how to make changes to improve your health? The same person who scribed your visit maybe? This would also free up physicians from being distracted by a computer screen and help them make a better connection with their patients.

Wow–a real win-win for patient care and engagement!

 

 

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A Short EHR Rant

No argument that EHRs began as billing platforms, though I will argue that they work just as poorly with charging as they do for communicating patients’ stories or making better decisions in patient care. After two years our EHR still isn’t used for billing and even if it were, since it has no Natural Language Processing capabilities, the doctor would have to manually enter the correct CPT code.Medical_Software_Logo,_by_Harry_Gouvas

My rant today is a brief one about how physicians document in an ambulatory EHR. On paper, we documented the patient’s story, any pertinent medical history and/or family history, the physical exam, our assessment and the plan (better known as a SOAP note). This was a short, succinct and usable communication device (assuming you could read the doctor’s handwriting). Today’s physicians, in the hopes of better compensation, pull in every possible bit of information into the note including their great great great grandmother’s penchant for getting hangnails. OK, that’s hyperbole, but it is almost that bad. And then complain that the EHR is a terrible way to communicate and that everyone else’s notes are too long.

Having been the “champion” for the EHR in our system I have a request to make — Hide, or have your assistant hide, all that past medical history. You didn’t put it in your paper note and IT DOESN’T NEED TO BE IN YOUR ELECTRONIC NOTE EITHER. If it’s a matter of training or you don’t know how to take it out, please ask your friendly IT trainer and they will gladly help you.

There, I’ve said it and I feel so much better!

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Physician Productivity

Maybe it’s my German ancestry that makes me enjoy reading productivity blogs. My favorite is Asian Efficiency but there are others that cross my blogging path. Today I came across this article: Why Your Brain Can’t Handle an All-Day Schedule.

ScheduleThis is not the first time that I’ve read about loss of productivity in environments where people sit in front of a computer all day. But it lead me to thinking about physicians who practice in present day medical office environments where the pressure of productivity is all-encompassing. Even though my schedule is not nearly as demanding as many doctors, on those days where I see more than 18 patients I realize that it is not only my intellectual capacity that plummets, but more importantly, my empathy quotient takes a nose dive. Somewhere around 4 pm, or #17, I am pushing away the weight of all the unfinished tasks, unfilled prescriptions and forms sitting on my desk as I try to listen to a patient problem. Couple this with the continual interruptions while trying to finish notes and it becomes obvious why physicians lack creativity if they remain in the typical constraints of a normal medical office.

Over the last several years primary care physicians have been pushed to see more patients, adopt new skills, like EHR, with steep learning curves while keeping up productivity-an oxymoron if one ever existed. This while we accept less pay, keep up with continuing educational needs and remain supportive to spouses, children and often elderly parents. If you add up the hours involved in just doing the above there is little space for exercise, reading, mediation or any other “leisure” activities that give life deeper meaning.

It is little wonder the creative element is lost on doctors.

Let’s hope new models of reimbursement, EHR’s that truly help us take care of our patients, Medical Social Media, improving patient advocacy and better models of care give physicians back some time–and with it, the creative art of medicine.

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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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Wear the White Coat-a leadership opportunity

The Greater Louisville Medical Society (GLMS) hosts an annual “Wear the White Coat” opportunity for leaders in the Louisville community to spend a day with a physician and get a first-hand look at what we do. When GLMS president Dr. James “Pat” Murphy put a direct plea into my inbox it seemed easy to volunteer.

The program began with a breakfast get-together to meet our shadows. Mine was London Roth, an enthusiastic Human Capital Consultant executive with Humana. It took me a while to understand what her job is but both of us are avid social media advocates so it was a match made in heaven. On a Monday morning London joined me for five hours during which most of my patients allowed her to accompany me in the exam room. She listened to their medical issues and participated, with the patient’s permission, when they had questions of her. She was observant, interested and insightful. She was indulgent as I ranted about issues with her company, as well as other payors. She asked lots of questions.

London and Kathy

Kathy & London Selfie

She commented on the awkwardness of our EHR system. She saw first-hand that, even if it is well-intentioned by the insurance company, sending over-worked clinicians patient information of who has not had colonoscopies, mammograms, pap smears, etc. are next to useless.  Who in the office has time to work the data, especially if it is not as accurate as the insurance company believes? London also listened to patient stories about how her company’s HR policies affect employees’ ability to care for themselves and their families.

We met again at a dinner organized for the group where each “shadow” related their experience. State politicians spoke about better understanding when legislature affects physicians’ ability to practice. Business leaders talked about how seeing the effects of poor health habits reenforced the need for encouraging their employees to have healthier lifestyles. Community leaders saw how patient support systems (or lack thereof) can determine the success of patient care plans.

Personally, London gave me two gifts: she ended her comments with how well I knew about the little things that were important to my patients, the human connection that makes for a better patient-doctor relationship. And she designed the best iPhone case ever, a gift to me illustrating one of my frequent questions to patients:IMG_5730

Programs like this give IRL* examples of how physicians and patients are affected by the decisions of community leaders and what they can do to impact change in their companies and legislative bodies. As Dr. Murphy said “when you wear the white coat, it becomes part of you forever”.

 

 

*IRL = In Real Life a frequent expression used in Social Media. http://www.urbandictionary.com/define.php?term=IRL (caution, this link contains foul language).

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