Blog Post Archive

HIMSS -- Second Year Thoughts by kathynieder - 03-16-2016
Having just returned from my second Himss conference, the massive HIT conference held this year in Las Vegas, I have a few thoughts on what I learned and felt. The weather was wonderful and the Sand’s participatory Healthcareconference center was a brisk 15 minute walk every morning from my hotel. With 45000+ individuals amassed in one space, walking helped to prepare for the day. Since it was outside the “strip" with few people having the same idea, it was a quiet experience. Walking into the conference center was time to brace for the onslaught of humanity where the #Himssanity hashtag makes all kinds of sense.
My personal theme for this year’s conference was Relationships. Since following healthcare thought leaders in the e-patient and HIT space is my main purpose for Twitter, it is wonderful to go to the Himss and see IRL (in real life) so many thoughtful individuals who are working to make healthcare safer and more efficient for patients and physicians. It began with a reunion with Jan Oldenburg @janoldenburg the night before the conference where we talked about her new book, a followup to ENGAGE!, that will come out sometime later in the spring. Here's a scattering of thoughts regarding other people I spoke to: Charles Webster (@wareFLO) was all about workflow. Having been through three GoLives in rapid succession right before the conference, improved workflows sure hits close to home. After years of seeing Mandi Bishop @MandiBPro on line,  she proved to be incredibly energizing with a vibrant personality that infused anyone near her with a “can do” sort of feeling. Zubin Damania, better known as @zdoggmd performed his EHR State of Mind at the AthenaHealth Cloud party Wednesday night. That was fun but I'm still a little confused about night clubs with full-size pools and little "mini-pools" around the periphery. Water, darkness and alcohol seem like a dangerous combination.
Himss has developed a strong social media presence and the official Social Media Ambassadors, as well as unofficial ones, kept attendees in the loop by live tweeting educational sessions and having social media tweet chats that kept conversations going outside the conference in the twitter sphere.
Pink socks were everywhere and Nick Adkins (@nickreeldx) seemed amazed by how they’ve caught on Fashion flawsince he began handing them out at last year’s Himss. We chatted about how people need a symbol to push the need for healthcare innovation forward and his socks are providing that. Another personality driving patient engagement and innovative care could be found in the Xerox booth where Regina Holliday painted daily. Her jackets were seen sprinkled throughout the conference. It was a thrill to be stopped by someone who wanted an explanation for the artwork on my back.
It’s reassuring to see so many talented individuals being heard at Himss regarding patient empowerment. Just in the two years I’ve attended Himss the voices are becoming a force to be reckoned with—the vendors are listening.

The Epic Circus Winds Down by kathynieder - 11-12-2015
For the last two weeks I've had my head down jumping through hoops, working hard to personalize Epic so my [caption id="attachment_1110" align="alignleft" width="288"] JEFF HEINZ/The Globe Gazette JEFF HEINZ/The Globe Gazette[/caption] 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?
GO LIVE, Day One by kathynieder - 10-28-2015
All the patients in my office who were inconvenienced yesterday deserve my thanks. They endured long processing times and our somewhat distracted visits with grace and good humor. They should be rewarded, as some of them waited over an hour to see me and all of them spent much longer in my presence than usual and without my utmost attention. The morning began with a tweet from one of my twitter friends, based on my previous blog post: Screenshot 2015-10-28 18.31.10 It was rainy, dark and cold but on entering the office the bustle of extra people made it cheery. That seemed an auspicious start. Administration cut our patient schedules by half, much improved from our last implementation when lessened schedules were frowned upon and the physicians had to worry about their paychecks. This decision has created a learning environment. My colleague was an incredibly good sport, despite the fact that she was given less than adequate support because, for some reason, there were no Epic personnel in the clinical area of our office. The trainers are as newly minted as we are. For geeky me, this was a puzzle to be solved and between our clinical superuser, my personal trainer (who is actually an administrator superuser) and myself, we could usually ferret out how to do something. Of course we were never entirely sure we'd made the right choice and there was the frustration that the same problem would have been solved in 30 seconds with an Epic specialist to show us. Toward the end of the day we had Meg from Medsys who shortened my learning time significantly and I was able to begin the personalization process which will make documentation faster and easier. We had significant hardware/Citrix challenges including timeouts, frozen screens and difficulty signing in. The front desk personnel were registering patients in an impressive timely manner until they had a  motor vehicle insurance issue. Things slowed down to a crawl. However, the front staff was engaged and not overly stressed. They commented that their "on the job" training was many times improved over the classroom training. The hardest thing for me is the flow of charting. Learning to document an encounter instead of a note makes sense in the electronic record but it's been exasperating to tie the visit together because elements are in many places of the encounter--did I do all of the physical exam? Where is the physical exam? Did I renew the meds? Where are the meds? Did I order labs? Where are the labs? Which labs did I just order? How do I know I'm finished? It is no longer a linear process. The jury is out on that--there is no summary screen to review to ensure I've covered everything. I feel as if I've created a documentary mosaic. The implementation staff responded quickly to our complaints and concerns, working hard to find answers to our questions and being honest with us. I applaud them. My first impression after day one is that Epic is not as intuitive as it should be. It has many ways to accomplish the same thing which is a strength as well as a handicap. It will help me document faster than my previous EHR and it has the capacity to remind me of health maintenance such as mammograms and vaccines that are due on patients. It does not yet have clinical support tools embedded in the software and I look forward to that. I don't love it, but I will probably like it some day and it's already a huge improvement on my previous system. It's no circus but that's probably a good thing. I really don't like clowns. Next week, next update.
Training, Take Two by kathynieder - 10-26-2015
Second day of Epic training went well. We were taught Inbox processing and how to interact with the patient portal. This was miles more straight forward than documenting a patient encounter. The following morning was "personalization lab" where things that are done every day can be made into macro-like phrases or entire notes, to make documenting faster. Unfortunately on arriving for my training, I couldn't get into the live environment. For an hour and a half. Our trainer kept calling the IT security folks who would  say "She should be able to get in now". Nope. After one and a half years of preparation for this moment, they waited until the day before to give us access. Seriously? Since anything that can go wrong does, why was that felt to be a good idea? The afternoon was spent in a dress rehearsal. Thank GOODNESS we did this before seeing live patients. The hardware, which had been tested with two previous technical dress rehearsals, did not work as expected. Multiple issues ensued and I have minimal hopes that GoLive will not see similar problems crop up. It took up to two minutes for the Epic software to load on our thin clients . In order for us to get faster loads we had to get rid of the ability to open up our previous software in the exam rooms. This means, in order to see the patient's old charting, I will have to carry another piece of hardware or leave the room. Not efficient, especially since there is also trouble with the database with all our scanned information. Next we discovered that logging into the thin client took us to our patient schedule instead of straight into the patient's chart. Not only an efficiency problem, but a compliance issue since a patient could theoretically see othecow-245690_1280r patients' names and reason for visit. We had software issues as well but those were minimal. Of course with no trainers to help the end users, we could accomplish only the minimal tasks our eight hours of training gave us. Go Live should be interesting--my associate has armed us with dark chocolate M&Ms (since alcohol would be frowned upon) and is bringing a cowbell to make sure she has no trouble getting the trainers' attention. Cowbells, chocolate and a shiny EHR software right out of the box. What could go wrong?  
Will My Charting Be Epic? by kathynieder - 10-18-2015
"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?