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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Let’s Ring in the New to Get Back to the Old

While reading a blog post by Dr. Kent Bottles I was struck by a quote from Lewis Mumford: 

“For most Americans, progress means accepting what is new because it is new, and discarding what is old because it is old. This may be good for a rapid turnover in business, but it is bad for continuity and stability in life. Progress, in an organic sense, should be cumulative, and though a certain amount of rubbish-clearing is always necessary, we lose part of the gain offered by a new invention if we automatically discard all the still valuable inventions that preceded it.”

Although Mr. Mumford has been gone awhile (22 years), part of his foresight, as I understand it, is that technology should serve humankind and not vice versa. The more things change the more things stay the same. Technology is infinitely more complex which makes it incumbent on IT and medical professionals that it serve to improve patient care and not worsen it. While I am jumping on the EMR (Electronic Medical Records) and Medical Social Media bandwagon, I am anxious to see that it is done in a manner that serves the patient more than me, the IT guy or the hospital where care is given. So many of the EMRs that I have sorted through as a provider makes patient care HARDER, not easier. Perhaps this will improve when, and IF, our different systems can talk to each other but now it is difficult to find labwork, tests, and pertinent history when wading through thirty pages of printed material that has nothing to do with the patient’s problem. The important stuff gets lost in the minutia.

The EMR train has left the station and we will ultimately all be on board (how many transportation idioms am I going to use in this blog…). I see Social Media as a means to better care for patients, specifically as a way to return to patient-centered care and much more importantly, to get on the bus of participatory care. In The Social Media Course a well-known advocate for patient participation in their own medical care, e-patient Dave, addressed the fact that patients are the most under-utilized resource in healthcare. The best clinical teachers I had in medical school taught me that if I listened to my patients, they would tell me what was wrong with them. After many years of medical practice I know with certainty that no truer words were spoken. With the wealth of information on the web physicians and patients can work together as partners, a manner of practicing medicine that has very little down side.

To get back to Mr. Mumford, my vision for the future of medicine includes accepting what is new because it brings us back to what is old–taking care of the individual patient (the old) by utilizing the new (Electronic records and social media) and in the process creating partnerships with patients as well as other physicians and healthcare providers. This doesn’t mean that my “partnered” patient will get the inappropriate antibiotic she insists is necessary. But it does mean that patients may once again see me as something other than a prescription supplier and test taker. Dialog is so much more satisfying than one-way conversation.

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To email or not to email…

Using email to communicate with patients is controversial both inside and outside of medicine. Not only have recent articles in medical literature addressed this but the Wall Street Journal published a very recent Yes/No opinion discussion on it. There are multiple issues involved–security, HIPAA compliance (which can involve hefty fines if one is found non-compliant), ensuring that patients understand the parameters for email use, concerns about liability, and time constraints among the biggest that come to mind.

The AMA has published guidelines for physicians that want to use email in their practice. Most of them are common sense suggestions but some are burdensome and difficult to communicate during an already foreshortened visit thanks to the time constraints most doctors have in practice. For instance, I am supposed to “Request that patients put their name and patient identification number in the body of the message.” My patients have no clue what their identification number is. I could request their date of birth but at this point they get my email address from my staff or from my business card and there are only five or six people who utilize it. I do print all communication out (since I don’t yet have an Electronic Medical Record) and so far I have had no trouble identifying who I’m talking to…Another recommendation is “Instruct patients to put the category of transaction in the subject line of the message for filtering: prescription, appointment, medical advice, billing question.” With only a very few people out of my population of 3000 are asking for this type of communication, it’s ludicrous to create a strict policy with emails.

It is amusing that the development of these guidelines was prompted by request of the Young Physicians Section of the AMA in 2000 (and it hasn’t been updated since 2002). It’s amusing because “young” people these days hate email. They use social media, eschewing email as much as possible. That’s a topic for another day but I understand that point of view. Email is cumbersome by contrast to Facebook messaging or texts even though it is more professional.  Also of interest is a separate publication by the AMA on the Ethical Use of Email with patients. Also very common sense kind of recommendations but I venture to guess most physicians have no idea this advice is on the AMA site.

So what’s my feeling on using email? Well, as I mentioned above, I don’t use it with very many people so at this point it is not a big issue. I find that the majority of individuals do not abuse the privilege and have short, to-the-point messages requesting refills or clarification of some minor medical question. The patients are in all ranges of ages, from early twenties to mid-seventies. If the question is too lengthy, I ask them to make an appointment. As mentioned above, I print out almost all emails and put them in their paper charts (what’s wrong with that remark!) Emails do not take the place of phone calls because I reserve phone calls for more lengthy explanations of lab results or other tests where I need to be sure the patient understands what I am saying. Really bad news is only given in person, so that’s not an issue. So far it’s been a helpful supportive tool. It is possible that I’ll change my mind as things evolve, or perhaps a social media site will take the place of email entirely. 

In the meantime, those patients who do utilize email to communicate with me really seem to appreciate the opportunity and don’t abuse it. It seems like another good tool for bettering patient communication and that’s a plus.

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Seriously, any problem reading this?

Unsurprisingly to me, a recent study published by the Journal of the American Medical Informatics Association (–study-finds) determined that there were the same number of errors with electronic prescribing as with written prescription. Same number, but the errors were different. Unsurprising to me because now that I’ve been e-Prescribing for more than five years I actually make MORE errors on-line than I do when I write them out. Of course this is partly due to the very strict Catholic sisters who oversaw my writing development in the 60’s, ensuring that my penmanship was legible. If you don’t believe me, ask any of the east-end Louisville pharmacists who have to fill my prescriptions. They LOVE them because they can read them.

Having said that, the study did imply that most electronic prescription errors are correctable IF the software is properly designed. In my own practice, using  an Allscripts product, I make certain errors on a regular basis (sigh):

  1. The script is sent to the wrong pharmacy. This is a software error I have bugged Allscripts about for a couple of years now, but it falls on deaf ears. The default setting is to send the prescription to the local pharmacy. There should not be a default, the physician should have to choose either a mail order pharmacy or the local one. This happens weekly and the patients are angry when their medication doesn’t show up in the mail (they ignore the reminder call from the local pharmacy). Ultimately, when the medication never shows up in the mail, my office gets an irate call from the patient wanting to know why Dr. Nieder sent the script to the wrong place and now they won’t get their meds on time and they will have to pay extra for a 30 day supply (or more likely–go without). But for some reason Allscripts doesn’t think this is a problem…
  2. It’s the right medication but the wrong dose. I often look on the medication list in the chart to choose the dose and if it’s not been properly updated the patient gets the wrong number of milligrams. This is usually an easy thing to fix by cutting the pill in half or doubling it, but annoying none-the-less. Hopefully this will improve with electronic medical record documentation…then again, GIGO.
  3. The prescription is sent from my computer but never makes it to the pharmacy. This typically occurs with mail order pharmacies. I don’t know why it doesn’t go “through” and Allscripts hasn’t yet provided the physician with an adequate way of knowing when it doesn’t make it. Hopefully communication processes will improve and I’ll see a little flag on my desktop someday as a notification. As it is, the patient calls and informs us, we go through a lengthy process in the system trying to see what went wrong and then resend it, crossing our fingers that THIS time it works. Yet another situation where the patient will go without or get a temporary supply at the local pharmacy until their medication is mailed.

Ultimately e-prescribing will be a safer alternative for prescribing medications but it isn’t quite there yet. It irritates me that there is not a board of prescribing doctors that routinely report to the Allscripts software development group to help make the process more physician-friendly. Instead the company relies on a “Client Connect” on-line community. If you’re at all tech-savvy you know that this process is only as good as the people “patrolling” it and since these are not physicians, clinical issues may not be obvious for the IT guys to “get” what the fix needs to be. I’ve already had this experience talking to the support people with Allscripts.

Soon, I won’t just be electronically prescribing, I’ll be documenting like many of my colleagues. Something I’m not looking forward to because so far, none of my peers have been happy with the process or the result, all of them have been frustrated and few see the light at the end of the tunnel as anything but a train…

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