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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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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Google Glass in Primary Care

Google Glass is in its infancy, with over 8000 “explorers” who are eager to find compelling uses for it. The concept is cool: A hands-free cell phone that is voice activated. A month ago my healthcare social media friend Kathi Browne, who is a Glass Explorer, proposed driving to Louisville from Knoxville to allow me to play with Glass for two days.

Kathi Browne‘s Google+ site

I was excited to accept her generous offer. She was equally accommodating about spending two days in my home which is presently a construction area with two cats, to which she is allergic. She seemed to tolerate the experience admirably.

As expected with a beta product, we had a few setbacks. We couldn’t tether Glass to my iPhone unless I gave up my grandfathered unlimited data plan. That wasn’t happening. Next we tried using the local network in my office. When that didn’t work we thought we’d found an answer jumping on my MiFi. That was great until Glass went into sleep mode (which is frequent due to a short battery life) which disrupted the MiFi connection and I couldn’t get it back online until the battery was taken out of the unit. It isn’t easy to remove. Finally Kathi just handed me her phone and I stayed live on her account.

The main advantage over a regular smartphone is how surprisingly unobtrusive the device is, both to you and the patients. It’s easy for the wearer to ignore it except when in use. Patients were of three varieties–too polite to ask what was on my head until I brought it up and then not caring, knowing immediately what it was and wanting to play with it, and being unaware of the product but excited to learn about it. No one appeared worried and the first thing I told them on entering the room was that it was not recording.

While it’s easy to understand how surgeons, teaching physicians or ER personnel might use Glass, its implications in the primary care office are less clear. A few thoughts:

  • Glass is much less obtrusive than the laptop I carry or even the chart I used to carry. If I could dictate into the EHR this could enhance communication with patients.
  • Having a projection screen that would show the patient what I was looking at could be used for education, the way I sometimes use my iPad now. For instance, I had a patient with shingles on her back and I could project her rash or a reference rash for comparison. I can do that with my iPad now but that involves carrying an iPad and a laptop. I don’t use the laptop for education because the screen is awful.
  • On the down side, there is no unobtrusive way to Google a question using voice activation. My patients would know exactly how dumb I am. Wait, I already do that with them on the laptop so with Glass I could look cool and dumb.
  • In a rural setting, sending a picture or a video from the exam room to a specialist would be advantageous but no more than telemedicine could do.
  • Calling up an examination video for something I don’t do a lot of, like a specific orthopedic exam, could be helpful but I’m not sure about the patient’s reaction. They usually prefer to think their doctor is well-versed in such things. Back to cool and dumb.
  • It’s quicker to Google with Glass, an advantage over a cell phone.
  • The voice recognition is amazing. Odd names and medical terms were usually nailed on the first try. However, there didn’t seem to be a way to correct recognition mistakes.
  • I suppose patients would get used to it, but would they worry that I was secretly recording them?
  • As Clive Thompson commented in today’s New York Times[1], using Glass is uncomfortable enough that constantly looking at the little screen is not an option. That could improve communicating time instead of the way the EHR takes away from it.
  • How about an app in Glass that would identify a rash within certain parameters of likelihood? That is, a Watson for Glass. This was also suggested by Melissa McCormack of Software Advice in the Profitable Practice blog.
What I enjoyed most was the shear delight of several patients who wore it for a few moments. They were so excited by the device and its possibilities. Whether it will prove of use in the everyday practice of the primary care doctor remains to be seen.

1. Googling Yourself Takes on a Whole New Meaning http://goo.gl/WAAWki

Post was edited 9-4-2013 by request of Ms. McCormack to better describe her blog.

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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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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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