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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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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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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An EHR Fantasy

Now that I’ve been using my EHR for more than three months, the muscle memory has taken over but there are still only so many clicks I am capable of doing in any given moment. Locating the right forms to insert, deciding how many templates to download, determining if I should plug the microphone back in between patients or carry it from room to room, figuring out the most expeditious way to document in the problem list from a scanned referral note or lab results and finding new ways to record a note, these things are all going to take a lot of time. Yesterday I came across an interesting article by Marla Durben Hirsch from the FierceIT blog: EHR vendors propagating a myth about their products. Amusingly enough, the article made me daydream:

I am in a room with a patient, iPad in hand. With touchscreen input, I easily target any templated buttons with my finger (instead of missing it with the stylus because it’s not quite in the ‘sweet’ spot). There is a graphical interface that’s pleasant to the eye, usable and intuitive. Dictation feeds directly into the chart from an adequately programmed microphone IN the iPad, so I don’t have to cart a separate piece of equipment with a ten-foot wire. There are separate modules for each specialist and a broader one for me, the family doc. If I misspell a word, there is a spell-checker (incredibly, something my present EHR is without). To show an illustration to a patient I simply double-click the home button and choose the browser for the internet or another app to illustrate a point. If there’s a video I’d like a patient to see it’s up in an instant. From the iPad I can quickly email links, videos or relevant information to the patient. It rarely crashes, the screen can be enlarged or reduced depending on my needs. It is smaller than a laptop and less obtrusive than paper charts. I add apps specific to my interests or my patients. And they don’t cost an arm and a leg. 

Alas I come back to the real world where my stylus still has to be placed just slightly to the left of the circle I’m aiming at. When I suggest to my IT support that hiring gaming developers might be a great way to improve the interface of our present EHR I’m really not kidding. Seriously, making patient documentation something inherently usable would go far to improve the acceptance of them with physicians. Despite claims to the contrary, physicians LIKE tech. We just expect the tech to be user-friendly. More specifically, we expect EHRs to work like the apps on our phones and our tablets. What a joy to look at a screen like this:

From the app iBP by Leading Edge Apps LLC


But no, my screen is riddled with tiny mono-color dots and clickorrhea is the name of the game. 


While patient care is serious there is no reason why electronic documenting could not be a joy to use. As more digital natives enter medicine they will be more insistent that the software they use to take care of patients be as easy to use as the apps they use to monitor their heart rates with exercise, check in with Foursquare, or text their friends. From my perspective, they can’t get here fast enough!

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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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