Category Archives: Electronic Medical Records

Patient Identifiers, Hospitals & the EHR

FIngerprintCurrent Joint Commission standards call for the use of two patient identifiers to avoid mixing up patients with the same or similar names. For inpatients, these identifiers are usually the name and the medical record number (MRN).

Which is fine if the only place you need to identify the patient is your own hospital.

But your hospital’s MRN is meaningless to me and my EHR.

So if you send me a copy of my patient’s chart (or her lab result or mammogram report) and all that’s listed on the top of the page is her very common name and your MRN, I have no clue who this patient is.

(My EHR gives me a box to check to confine the search to my own patients, but that button only works about 10% of the time.)

So please, hospitals, start adding the patient’s date of birth to your printed reports and records.  And EHR vendors, you could make it easier for all of us by defaulting to a header that includes the date of birth as an identifier.

Thank you.

 

Saved by the EMR

EMR LIFESAVER.Given all the complaining I and my colleagues do about electronic medical records ,  I thought I’d take the opportunity to tell you about something good that came from having my practice online.

A patient came to see me last week for a check up and requested a prescription for birth control pills.  She’d used them in the past without problems. I wrote the script and sent her on her way.

As I was finishing writing her visit note later that afternoon, I did what I usually like to do but had not had time for while she was in my office – look through her last few visits in the system with other docs. I noticed that she had had a recent CT scan for abdominal pain, something she had forgotten to tell me when I asked about interval medical history. A small presumed angiomyolipoma had been found on her kidney, and was being watched.

I seemed to remember that there was something about angiomyolipomas that could be problematic with hormones. A quick foray into Up to Date and Pub Med reminded me that these tumors, though benign, have receptors for estrogen and progesterone, and have been reported to grow, sometimes rapidly, in pregnancy and on birth control pills.

I immediately called my patient to discuss the issue, and advised her not to fill the prescription I had given her for birth control pills. She would continue to use condoms while considering a copper IUD for birth control. I updated her problem list and medical history to include the CT finding, so that the next doc to see her would find the issue up front instead of fortuitously stumbling onto it while poking around her chart after the visit was over.

This is actually not the first time I’ve happened upon clinically critical information in the EMR that my patients have forgotten to tell me. It’s the one area where the EMR can really make a difference in outcomes.  Of course, this only works when patients have a small enough record, as my patient did, for me to poke around in a few seconds, and best when providers write concise, relevant notes (something the EMR does not facilitate) and update the history and problem lists accordingly.

I’m sure one day someone will figure out a way for that kidney tumor diagnosis to automatically prompt a warning when I go to prescribe birth control pills, but for now I’m happy just to have access to all my patient’s information in one place.

The EHR is the Frankenstein of Modern Medicine

Frankenstein EMRWe created the electronic health record, but if we can’t figure out how to contain it,  it may just destroy us.

A recent study at Johns Hopkins University indicated that hospital interns — physicians at perhaps their most formative stage of training — spend only about 12 percent of their time interacting with patients. By contrast, they spend 40 percent of their time — more than 3 times as much — interacting with hospital information systems. The flesh-and-blood patient is getting buried under gigabytes of data.

The Drawbacks of Data Driven Medicine by Dr Richard Gunderman in this month’s Atlantic Monthly.

A must read for docs and patients alike.  Comments section rocks too.

Adapting Office Workflows to the EMR – or How I Restored Patient Face Time & Got Back the Joy in Medicine

The Problem : Lost Face Time = Lost Joy

One day, about 5 years into using the electronic medical record in my practice, I came to the realization that I wasn’t having fun anymore. I was sitting throughout most of every office encounter facing a computer screen, my back to the patient on the exam table across the room. The joy of face to face interaction with people, the real reason I went into medicine in the first place, had been replaced with the more pressing urgency of data entry.

My revisit routine went something like this – I’d enter the room, briefly greet the patient (undressed and sitting on the exam table) and then, apologetically saying “Let me just open your chart”, I’d log on and begin interacting with the more immediately demanding presence in the room – the EMR. I’d turn around as often as I could to look at my patient, but mostly I listened but kept my back to her and I typed. After which I’d rush over to her side, do the exam, then head back over to the computer to make sure I got all her orders, refills and charges in as required.  A brief goodbye, and I was on to my next patient.

As more and more mandatory clicks were demanded from the EMR to prove I was a good doctor – smoking history reviewed (click), medication reconciliation  (click, click, click,click), problem list review (erase duplicates from ENT , remove resolved problems, add today’s, then click that I had reviewed what I just did) – the actual moments of face time with my patients had become smaller and smaller, till they were almost an annoying distraction from the real task at hand – finishing my charts.

I found myself spending office hours longing for them to be over, and even more sadly, wondering just how many more years I needed to do this before I could retire.

Something had to change. Since the EMR wasn’t going anywhere, it was going to be up to me to make it work.

Renovating the Exam Room was not the anwser

My internist has a patient chair next to the desk in the exam room – I talk with her there, then she leaves the room while I change, then she comes back and does the exam, finally wrapping things up at the desk while I wait in my gown. Then I dress after she leaves.

I thought about pushing for our exams rooms to be renovated, but realized that I probably wouldn’t adopt my internist’s workflow. It just ties up an exam room for too long.

Advance chart prep was not the answer

I tried doing what some of my colleagues do – reviewing the charts of my patients the night before, creating a presumptive note based on her history and the scheduled reason for her visit (when I knew it) , even entering charges and orders for mammograms and birth control pill refills, all of which I could quickly edit and sign tomorrow when I saw the patient, freeing up the encounter itself for more personal interaction.

That idea lasted about a day. While it may work for surgical sub-specialists who hold office hours twice a week to prep charts the night before, it’s impossible for a doc like myself who sees between 15-24 patients a day, 4 days a week.  I had to find a way to get today’s work done today (and not at 4:30 am today, which is when another colleague does his chart prep).

Changing office workflow was the answer

I realized that my private office, which sits between my two exam rooms, is arranged so that I can type and look at my patient at the same time. So I decided to reserve all my electronic charting to my office, and leave the exam room to do what it does best – exams.

My patients now come to see me in my office before and sometimes after they’ve been examined – a workflow previously reserved for new patients. It’s a little more complicated for the office staff, but it’s working really well for me and for my patients. We’re both more relaxed and can both look one another in the eye while we talk and I type.

Its not just the office staff who’ve had to get used to the new workflow. Long-time patients can get thrown, despite my staff explaining that this is the new routine. One patient told me she felt like she was being called to the principal’s office. Another was convinced I had bad news for her. Once I explain my rationale, however, my patients are more than pleased with the new arrangement. Some have remarked on how much they like my office, and how its decor and wall art has allowed them to get a better sense of who I am.

Other pluses –  I’m no longer wasting precious time logging in and out of the EMR, since my office computer isn’t used by anyone but me. I’m physically more comfortable, and so is my patient. Our wrap up after the exam is that much more personal because I am able to enter her mammogram and refills and even her charges while she changes instead of in the exam room. I remember more of the visit later because I’m more fully present with the patient in the exam room. Finally, there’s less down time for me, since I’ve effectively added a third room to office hours and can see a patient in my office while the other two patients are either dressing or undressing in the exam rooms.

But the biggest upside to my new workflow? I’m having fun!  It’s like falling in love with medicine (and my wonderful patients) all over again.

The down side

The down side to my new workflow is that I’ve got to hold everything in memory between the time my patient leaves my office and when she is ready in the exam room, during which I may have seen another patient or two.  It can take me a second or two to ascertain who’s behind door number two, and sometimes I get it wrong. Which has led to an embarrassing moment or two when I opened the door with a comment related to a prior conversation in my office and realize the person behind it is not who I was expecting to see. I’ve since learned to keep my mouth shut until I’m entirely in the exam room.

The good old days 

In the good old days, I could pick up a chart from the rack outside the door, and in what seems life a few seconds, familiarize myself with my patient’s history (because I kept a great paper chart if I do say so myself…) before opening the door to greet her. During the visit, I could sit with the chart in my lap, jotting down notes as we spoke, my focus on my patient and my thoughts rather than a user interface. Once the visit was over, a few brief jotted notes and some well-placed check marks on the encounter form summarized the visit, a few scribbles on a prescription pad or radiology order form clipped to the chart finished the orders (the rest taken verbally by my tech), a check off or two on the superbill and I was done. The entire work of a patient’s encounter took place in one room (or just outside its door), and in one allotted space of time, during which I was hers and hers alone. My chart was there, sure, but it was not the dominant presence in the encounter the way the EMR is now.

Is the IPad the answer?

I find myself thinking a lot about the Ipad these days. While initially skeptical about its place in healthcare, I’m beginning to think that it may ultimately provide the best workflow solution for me. However, I’m worried about my ability to type into it – something that’s not easy to do standing up.  And its compelling interface could be even more of a distraction than the desktop. But its portability could allow me to review a patient’s chart outside the room just like the old days, and things like favorite lists and drop downs in the EMR could minimize typing.

Our EMR vendor at this point only offers a limited version for the Ipad, something that may be useful on call but not robust enough for office hours. So nothing new anytime soon.

That’s okay. I’m happy again. I can wait.
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Pauline Chen,MD wrote about this issue last year in the NY Times. She points out that some docs seem to handle the distraction of the EMR better than others, integrating it more seamlessly into their practice. If you use the EMR and have a workflow that works well for you, tell us about it in the comments. 

The Meaningful Use Song (with Apologies to Gilbert & Sullivan)

As billing compliance leader in my department, I’ve been charged with getting my colleagues on board with Electronic Medical Record Meaningful Use. (What does meaningful use have to do with billing? It’s complicated, but the codes up until now have been reported along with billing codes, so it sort of fell into my lap. Lucky me…)

Generally, meaningful use refers to using the EMR in a way that harnesses its immense power to store and retrieve data in a way that makes sense and potentially improves clincal outcomes- by checking for drug interactions in real time, for example, or to track blood sugars, blood pressure or other data, or to allow for electronic prescriptions and shared data between clinicians using common language.

Specifically, when we say “meaningful use” these days, we are referrring to the list of meaningful use standards developed by CMS – a very specific list of 25 objectives, along with defined quality measures (like percent of women getting mammograms) that will be used to report and track health outcomes in practices using EMRs.

CMS is offering financial incentives to medical practices to use their EMR in a meaningful manner this year. We will be reporting data starting in October 1 to CMS, and must meet 20 of the 25 meaningful use objectives and report outcomes on chosen quality measures to qualify for the incentive payment. In addition, we are reporting separately to the government on the use of electronic prescribing, and face possible penalties for docs who are still stuck on paper. In time, our outcomes on the quality measures will be reported to the public on the CMS website.

Does Meaningful Use Improve Clinical Outcomes?

That’s the 20 billion dollar (the amount 2009 Hi-Tech Act allocated to the meaningful use incentive program) question. We really don’t know as yet whether or not EMR use itself favorably impacts patient care.  Some studies say EMR use does not improve health outcomes, but more recent studies of diabetes care and in low resource areas have suggested that EMR use may be beneficial.

We also have no idea if docs who attain meaningful use are better docs than those who don’t. Despite this, the CMS website will have clear implications as to the outcomes of doctor’s practices in terms of standard quality measures. It’s a bit worrisome to me, especially since so many of the outcomes are driven by patient compliance (a word I know a lot of my readers don’t like, but there it is…) Not to mention the thorny issue of using mammogram screening in women over 40 as an outcome measure when we just decided that it is no longer recommended to routinely perform it in everyone. (Don’t get me started on that issue again…)

Overall, I think meaningful use is a step in the right direction

I do see meaningful use as an attempt to rein in the wild, wild west of EMR development to try to create some standardized functionality and communication. It’s also a way to begin to corral the freestyle and autonomous EMR use that has evolved among early EMR users, who did what they needed to do to get their work done during the evolution of the EMR around them, but who now need to step back and reassess how well (or not) they are using this powerful tool that has been foisted upon them.

But my god, this whole process has been painful.

And so damned complicated, I needed a song to keep it straight. Ergo that parody up there, which actually covers all 25 meaningful use requirements as defined by CMS. (or at least as I see them…)

Of course, I could have just learned the Meaningful Yoose Rap. But please… me singing rap?

Managing my EMR Results InBox

My practice has been using the EPIC electronic medical record for 5 years now, and it’s taken about that long for me to figure out how to tweak the system to make myself more efficient, and for the system to evolve to a place where I could tweak it myself.

Case in point – Quick Actions.

EPIC’s most recent upgrade includes little self-made macros called “quick actions” that turn repetitive tasks into a mouse click. I’m using quick actions to manage my results in basket in much the same way you may be using Rules in Outlook to manage your email.

Some of my macros are actually little work-arounds for a system that is not yet entirely integrated and a patient population that has not yet embraced online results communication. About half of my patients sign up for online results – I’m working hard on the rest…

Like many of you, I like a clean inbox, but need a place to park messages that are awaiting some future task for completion. I’ve decided to use the “results notes” inbasket for this purpose, so you’ll see some of my macros moving messages there.

I now have the following Quick Action options whenever I view a lab report –

  • Normal Pap – creates a standardized normal pap letter, sends it to my secretary to print out and mail and inserts a little addendum note to the encounter that results were sent.
  • Left message – After I’ve called and failed to reach a patient about a lab result, adds “left message ”  addendum to the patient’s visit note and moves lab result to my results note in-basket, where it will sit till she calls me back (or I call her again, don’t get me started on the phone tag game…).
  • My Chart – Inserts a little note into the patients EMR that her results were released to her via My Chart – an online patient communication system that sort of lives outside my EMR with incomplete integration, so I put that little note in so I know I communicated results to her. It’s faster than searching through the My Chart inbasket later.
  • Hold for HPV – Moves mildly abnormal pap results into my results notes inbox where it will wait for the HPV result, which comes a few days later.
  • Failed mammo – creates a reminder letter to patients who have failed to get their mammogram, the order for which is sitting in my “overdue results” basket, and sends the letter to my secretary to mail it. I then delete the overdue message from my inbasket.

Any other EPIC users out there have Quick Action macros that are working well for them? If so, feel free share them with us in the comments section .

The EMR and the Pathologist – A Winning Combo

A pathologist uses the EMR to find out just a little more about the patient whose cerebro-spinal fluid she has under her microscope – and changes her diagnosis.

This patient had a diagnosis of plasma cell myeloma with recent acute mental status changes. So the lone plasma cell or two I was seeing, among the lymphs and monos, could indicate leptomeningeal spread of the patient’s disease process. I reversed the tech diagnosis to atypical and added a lengthy comment – unfortunately there weren’t enough cells to attempt flow cytometry to assess for clonality of the plasma cells to cinch the diagnosis. But with the information in the EMR I was able to get a more holistic picture on a couple of cells and provide better care for the patient. I cringe to wonder if I might have blown them off as lymphs without my crutch.

The much hoped-for improvement in quality due to the adoption of EMRs has been elusive to date, so anecdotal experiences like this will be important evidence to consider in judging the impact of the EMR on health care outcomes.

Kudos to pathologist Gizabeth Shyner, who writes over at Mothers in Medicine and her own blog, Methodical Madness,  for “Thinking Outside the Box”.

Is Healthcare ready for the IPad?

First off, I need to address those who think they’re being brilliantly funny comparing Apple’s new product name to a feminine hygiene product – making comments like “Does it come with wings?” and “It’s light and easy to use, but can you swim with it?” (these are the cleaner comments I’ve seen), or calling for the next generation ITampon.

Since when did the word “Pad” become unusable in public discourse? And where were these folks when IBM came out with their Think Pad? It’s stupid, 12-year old funny and just plain dumb. Grow up, ladies and gents.

Now, on to more serious matters.

Is the IPad, as some are suggesting, the next big thing in Medicine? Dana Blakenhorn at ZDNet thinks so, calling medicine the IPad’s “Sweet Spot”-

It’s what your doctor has been dreaming of ever ince the PC revolution began. Imagine this in a flip-up case, in every examination room at your clinic. The nurse sets up the chart, the doctor walks in with a stylus and examines you, and when he’s done the chart goes into the file and the prescription is waiting at the desk for you, printed clearly, along with your Coordination of Care Record. Hand the nurse your credit card and you’re off.

First of all, Dana, that script ain’t waiting at the front desk – it’s already in the pharmacist’s inbox. And my nurse isn’t the one swiping the credit card – my secretary is. But, more importantly, is Dana right?

Is the IPad what I’ve been dreaming of?

Let’s see – I already run my EMR on my PC at work and my Macbook at home, where I can multitask to my heart’s content, and don’t have to re-login to my EMR every time I move back and forth from that app to, say, my calendar, the web or my e-mail. Do I really want a device that does not multitask? Probably not.

You’re thinking it’s the apps, right? Lots of separate cool apps, all of which do really neat things like let me read EKGs or keep lists of patients or look up drug interactions. None of which talk or import data to one another and all of which I need to move back and forth between. Those apps?

Well, let’s see…My EMR looks up pharmacies and drug interactions, lets me access Up-to-Date from within my patient’s record, pulls in lab results from 3 different laboratory vendors and radiology reports from any of our offices and allows my patient to access these herself online. If she’s admitted to the hospital, I can access that chart through a different app, and the discharge summary and op notes make it into my office EMR. That’s one hell of an app, I’d say. Can’t think of too much more I need.

As for games and videos, I guess there’s always lunchtime, but I generally use that time to return phone calls, so…nope.

But wait – What if the IPad were to let me take a photo of say, a skin lesion, and plop it right into my patient’s chart – how cool would that be? Or I could Skype a patient and provide real time care over the internet – now we’re on the 21st Century! Oops, I forgot. No camera on the Ipad…

Maybe it’s the AT&T 3G network you’re thinking about. The one that drops my IPhone calls at least half the time? That 3G network? Not to mention I can’t access it anyway from my office, where the hospital’s concrete walls render even the best of cellphones powerless.

Ok, forget 3G. Maybe the IT guys at work will put in a router for me. That would be nice. Then, instead of being tied to my desk, I could go from room to room with my Ipad. But of course, I’ll need a way to keep the device clean. After all, Staph Aureus is ubiquitous, and has been found on hospital keyboards. Unfortunately, I don’t think I can use any of the current cleaners I have on the Ipad. That’s a problem.

The Real Question

It seems to me that the real question is not “Is Healthcare ready for the Ipad” but “Is the Ipad ready for Healthcare?” And the answer, sadly, is not just yet.

I’ll just have to keep on dreaming…
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More on the Ipad and Healthcare from around the Web
  • Dr Anonymous gives his thoughts on the Ipad – It’s the software, stupid.
  • John Halemka weighs in with some thoughtful questions about the Ipad’s suitability for patient care, but concludes it is “definitely worth a pilot”.
  • MobiHealth News takes the pulse of the Healthcare industry on the Ipad – Bottom line – not just yet.
  • IMedicalApps shows one place in healthcare where the Ipad shines – Anatomy Imaging
  • Brandon Glenn at Medcity does a great job summarizing the Ipad’s limitations
  • Chris Paton at the Health Informatics Forum likes the Ipad for docs – the comments from software developers are well worth a read if you want to see what the future for the Ipad may hold
  • Joseph Kim at Kevin, MD has 10 ways to use the IPad in your practice (none of which includes an EMR) 
  • Steve Woodruff , writing at Kevin Md, thinks the IPad will be a game changer in Healthcare. The operative word, in my opinion, is “will”.
  • Mike Kirkwood thinks a few EMR vendors, most notable EPIC (the one I use) are poised to enter the Iphone/IPad world. Now that would be very nice….

Tickler Systems and Thoughts on Mandating the EMR

Sometimes I feel like Elmo…

Dinosaur Doc posted awhile back about how she managed to keep track of a patient who was failing to follow through on a mammogram. Dino holds the charts of patients with pending studies on a special shelf in the file room, where they stay till the study comes back.

Dino’s got a tried and true tickler system, and it works.

My Old Paper Tickler System

I had a my own little tickler system before we went to an Electronic Medical Record. For labs and path, I had a cloth-bound log book, where my tech simply checked off the results as they came back each day before handing the pile of reports over to me for review. If the results didn’t come back, she called the lab. For radiology, we had a series of manila forders, one for each month of the year. When a radiology test was scheduled, the third NCR copy of the requisition was slipped into the pocket corresponding to the month in which the test was to be performed. As results came back, my secretary pulled the requisistions for the folder, and at the end of the month, anything left in the folder was overdue, and we contacted the patient. On my desk, I had a rack for the charts for patients who worried me or from whom I was waiting for call backs, and the chart stayed there until the issue was resolved or the game of phone tag was over.

My system was simple, it was fast and efficient, and it worked.

Tickling with the EMR

I’ve been electronic almost 3 years now, and have to admit, I still miss my old tickler system. What I’ve replaced it with is a bit more complicated. Here’s how it works (and anyone who has ideas on how I can do it better, please feel free to comment) –

Labs
This part’s easy. Most of my patients have labwork at our hospital, and the few who don’t go to Quest or Lab Corp, both of whom can send results electronically to our lab. I just head into my In Box to see their results. I go to the Overdue Results Folder once a week, sort it by type of test, and forward the overdue tests to my secretary. She then calls the lab or the patient (who occasionally skips out without their bloodwork).

If I am unable to reach a patient on the first try about an abnormal result in my In Box, I forward that result to myself as a Result Note, and those notes stay in a separate folder on the desktop till I hear back from the patient.

Rads
I handle radiology results in my In Box the same way as labs. But overdue rads are a whole ‘nuther story.

You see, our radiology system doesn’t really talk to our outpatient EMR as well as the lab does. It sends text files over to my In-Box, sometimes matching it to an order, but very often not, so it often fails to “done” my order. In addition, our system holds my orders by date of order, not date scheduled, and labels them overdue at some fixed point after the order date. Since we order routine mammograms months in advance, and because pelvic sonograms often have to wait for the next menstrual cycle to be optimal, every mammogram and sonogram I order becomes “overdue” at some point in our system. It makes for a very big and, for all intents and purposes, useless radiology tickler system.
Whenever I get a free day, I head into the Overdue Results Folder for a big cleanout, scanning each patient’s chart to see if the overdue test actually did come back and forwarding the ones not done to my secretary so she can call the radiologist before she sends a note or calls the patient. There is nothing I hate more than wading through an overdue folder filled with mostly things that are actually not overdue.

Today, after spending my entire Sunday cleaning up the Overdue Results Folder, I came up with an idea, and I can’t wait to try it tomorrow to see if it works. I’m going to order all my radiology as future orders, with an anticipated date around the time I expect it to be done. (I don’t know why I didn’t think of this before…) Of course, it’s now going to take me longer to place these orders, but I am hoping it will save me time at the back end and give me back a meaningful radiology tickler system.

Path
As for pathology, those reports come back quickly and pair nicely with their orders. But they lose their formatting when they come over from the path lab system to the EMR. Gone are the nice paragraphs separating the meat from the gravy, making it difficult to scan a report quickly to determine if it is normal or abnormal. As a result, I’ve actually missed a few abnormals since we went live with the EMR. Fortunately, our path lab still sends us a paper printout once a month of all our abnormal pap smears, and I caught my mistakes right away. Good old paper…..

Good Old Paper
Speaking of which, I find I still need a paper tickler system for those few patients I don’t want to lose track of. It’s quite a complex system – a lined paper pad that I keep on my desk. If I see a patient I am worried about, or get back a mammogram or abnormal pap that needs follow up testing, I write the patient’s name on the pad with a little box next to it. That box gets checked off when I get her colposcopy or breast biopsy results back, or whenever the issue at hand is resolved. I work through that list every 3-4 weeks or so, crossing things off and recopying the few remaining items to a new page in the pad to start all over again.

I wish our EMR would let me create my own folders for tracking my problem patients this way, but it does not. So I use paper.

I am not writing this post to whine or complain (Well, maybe a little…)


Our EMR is fantastic, and our programmers are top notch. As I sit in my bed at night reviewing labs or catching up on that day’s notes, or catch a medication interaction that I would have missed in the old days, I am forever grateful for the fact that my practice is electronic.

The problem remains, however, that we are still struggling to get our EMR optimized. It’s a patchwork created from different systems, each designed to do what they do well, but not necessarily all speaking the same language. As a clinician, I remain frustrated that we still can’t get them to talk fluently to one another. And that is why, in my humble opinion, we are not yet ready for mandated electronic medical records.

Because if we can’t even get our own internal institutional systems to talk smoothly with one another, how are we going to link up all our institutions electronically?

A Government-mandated EMR or Tower of Babel?

The current EMR did not just spring up anew one bright day. It has evolved over decades – decades in which the laboratories, radiology practices, hospital billing systems and some upstart clinical practices each took their operations to the computer, using propietary software systems developed specifically for their own niche. Dermatology and infertility practices each have online systems that were designed for the kinds of work flows unique to their business. Hospitals also have their own inpatient systems, which don’t necessarily translate easily into the physician office, and vice versa.

With all these separate systems out there, and more coming every day, I think we need to stop and take a deep breath before our national quest for an EMR becomes a government-mandated Tower of Babel. I don’t think any doc should be mandated to have an EMR until we have EMRs that can talk to one another. And our initial investment should not spending money on willy-nilly mandated installation of Walmart’s and other vendor’s systems, but on first developing a unified code and language to be used for all EMRs. Then we can see which of the currently used systems will fit into that paradigm, and spend our dollars tweaking existing systems or scrapping them for new ones that are up to code.

Perhaps we can take our cues from the banking systems. Those systems all talk to one another with a common language that has to work, or someone loses money. I don’t know how theses systems evolved, who set the standards or how they got universal agreement, but someone out there must know. Let’s get those guys onto our medical records task forces and see what they come up with.

Until then, I’ll be plowing through my Patchwork EMR Tickler system…

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My EMR and I

It’s only taken Grunt Doc four days to fall in love with his new electronic medical record (EMR).

It took me a bit longer that that.

But then again, I was never the head over heels type of gal. My feelings for my EMR were more of a slow burn than a raging passion, and we’ve had out ups and downs. We’re more like Hepburn and Tracy than Romeo and Juliet, sparring and fussing with one another, but always ending with a grudging mutual respect and admiration.

And, like any good Tracy-Hepburn movie, our story has had a few scary moments. But each time, my EMR rescued me from the edge of the precipice.

Take, for example, the patient who forgot to tell me about the DVT she had since I had last seen her 6 months ago. I was about to prescribe birth control pills for her, and saw a few visits with a hematologist in her encounter list. A quick perusal of those visit notes tipped me, and I immediately changed the script to a progesterone-only pill. Of course, if the hematologist had updated the problem list and history portions of the chart, I would have caught it upon opening her record. Or better still, if my EMR had found that history itself and popped up a warning flag when I wrote the prescription. But there I go complaining…

There was the time I somehow missed that my patient’s pap was abnormal. But I get a monthly summary print out of abnormal paps from our lab, and caught it on that review. Of course, the EMR does not actually distinguish normal from abnormal paps – the results are still just a text field. It takes the path lab to do the compiling of the list for me. But I’m not complaining, am I?

How about the fact that I can check patient labs and do my charting work at our cottage, allowing me to get out of the office a bit earlier on weekends, or even work from home on the occasion? Now that’s a real benefit of my EMR! Of course, I can’t place radiology orders from home, though I still can’t understand why…

And speaking of radiology orders, why doesn’t my EMR remember the appointment date and not send me an overdue test notice until after that date? And why can’t it print out a med list for my patients when they arrive, since most of them forget to tell me about at least one med that they are taking? Or present me a better summary sheet upon opening a chart, or god forbid, let me design that first view myself?

There I go again, throwing plates at the EMR I love.

Because I really do love it, you know.

Most of the time.

Online Personal Health Records – Does HIPAA Apply?

In my last post, I asked whether or not my patients should use an online personal health record (or PHR). I related how I had started and then stopped entering my health information into an online patient health information repository because I was worried about my privacy.

Turns out my instincts were right.

According to an editorial in this week’s New England Journal of Medicine, HIPAA rules don’t apply when it comes to the online personal health record.

Online data stored outside the health care system are not subject to the federal Health Insurance Portability and Accountability Act (HIPAA), which established minimum privacy and security standards for individually identifiable health information controlled by a “covered entity” — a health care provider, a health plan, or a health care clearinghouse. Because online data repositories such as Dossia, Google Health, and Microsoft Health- Vault and some of their business partners are not covered entities, the data they store may not be as private as consumers assume, and a person’s “control” could turn out to be limited.

I can’t imagine that as things evolve online, HIPAA won’t be updated to include online personal health record sites.

But for now, I’m staying clear.

EMR Purgatory – Not a Bad Place to Be

It’s been 21 months since I was forced to convert to an electronic medical record, and I have just now reached the point where I can say that the EMR has had a positive impact in my practice.

Converting to the EMR is not easy. This conversion is not like getting dunked in the river and seeing the light. It’s more like going through Dante’s Inferno. It’s taken me almost 2 years to ascend through the Circles of Hell and I am in Purgatory right now – things aren’t perfect, but I can see Paradise in the distance, and I’m glad I’m here.

Here’s what’s happened, and what is different.

1. When things get hectic, I no longer reach for a pen.

This change took about a year, because you have to get to the point where you don’t have to think and everything is automatic. Now I just head to the computer and type like a madwoman.

2. I am getting really good at typing while looking at my patient.

And at spell checker.

3. Most of my visits are now closed by the end of office hours.

When you are converting to an EMR, every patient is like a new patient, because you need to input their history into the computer at their first visit on the EMR. There was no time to do this during office hours, so I would catch up at the end of the day, evenings or weekends. Since most of my patients only come once a year or so, it’s taken this long to get everyone in.

This is the largest and final circle of EMR hell. But the payoff for all that hard work is that now visit documentation is a breeze – just update the meds and history, click on the exam elements, type in my notes and I am done.

4. Most of my patients’ prescriptions are now in the system.

I can bang though my refills in a few minutes by just pointing and clicking. Pretty soon, those refills will be going straight from my computer to the pharmacy, though for now my secretary is still calling them in. Cleaning out meds lists, though, is becoming a little maintenance chore.

5. My colleagues are helping me (and vice-versa).

About once or twice a day I see a patient who also sees another member of our faculty, and that doc has already completed the history, meds and allergies. That just makes me smile.

6. The EMR is changing my referral habits.

I’m starting to learn which of my colleagues uses the EMR the way I do, and which just short-cut their way through.

When you first convert, it’s extremely tempting to just start creating text notes using the text editor and macros, ignoring the custom fields for history, meds and allergies. It gets your charts closed faster. But if you just use the EMR as a fancy word processor, you’ll never see its true benefits. Plus you’ll make my life harder.

So, if I need to refer a patient to a colleague in another specialty, all other things being equal, it’s going to be the one who uses the EMR the same way I do. The docs who update the history and allergies and clean out the medication and problem lists once in awhile.

7. EMR creates transparency between practices

This is something I had not anticipated with the EMR. More often than not, I am impressed with the care my colleagues are giving. And I’m discovering some great new docs this way who I had previously only known by name.

8. Communication between docs is a snap

Just forward on lab and path reports with a brief note. No more phone tag. I even messaged my own doc to ask for some refills to mail in to my online pharmacy. Cool!

9. Of course, things aren’t perfect.

  • I need our nursing staff to update meds and manage the overdue results box. (Staffing issues…).
  • They need to figure out a way to input radiology appointment dates so that every mammogram I order months in advance doesn’t come into my overdue box a few weeks later.
  • The lab and radiology have different systems, and the interfaces can be tricky. This means that my staff still needs to print out radiology referrals and lab slips.
  • The EMR is getting too large. In another few years, negotiating through a patient’s chart is going to become a nightmare. Just scrolling down a list of visits can be time-consuming, not to mention filtering out the ones that matter, like doc encounters, from the ones that don’t, like refills. This is a job for the programmers – finding a way to have information retrievable but not in your face at all times.
  • I still need a sticky note function.

10. Because of the EMR, I’m making more money.

Gotcha! (Check the date of this post.)_____________________________________________

To read my previous posts on the EMR, go here.

When the Electronic Medical Record Goes Down

Shortly after 10 am on a busy morning not too long ago, our office electronic medical record system went down. It was a system-wide failure, and it lasted for over 12 hours.

Given that we had been online since last June, I was actually pretty impressed when I realized that we had gone as long as we had without a major glitch. But that realization didn’t help much while I was in the midst of busy office hours.

Because, as these things always go, we had done nothing in advance to prepare ourselves for the inevitability of a major EMR down time. Now, of course, we know what to do, and that is the point of this post – to prepare you for the same inevitability in the hopes that you won’t have to go through what we did.

Twelve Steps to Recovery from an EMR Downtime

Step 1 – Admit that you are powerless over the EMR – and that your practice has become unmanageable without it… Oops, sorry. Wrong 12 step program…

Step 1. Don’t panic. There is a back up. If you work in a big place like I do, I can’t imagine you don’t have a mirror server. Have you IT folks prepared to give you read-only access to it while they work on the problem in the background.

Step 2. Be prepared. You would be surprised how quickly all the paper disappears once you’ve been online for a few months. By the time we went down, we had nothing left but a few old lab reqs and blank computer paper. So, long before you ever need it, make a list of paper supplies necessary to function during a prolonged down time. Things like your old visit templates, superbills, radiology and lab requisitions, labels, receipts, message books, etc. Ask input from the entire office staff on this one. Gather a supply of these things (enough for several days if need be) and put it all in a big box or file drawer labeled “EMR Downtime supplies”. Make sure everyone knows where it is, and check it periodically to be sure no one has rifled through it.

And keep a supply of prescription pads locked away in your desk drawer. I had none, and ended up calling in all my scripts that fateful day.

Step 3. Go back to the future. While you are down, shift into paper mode, just like the old days. Write your SOAP notes, check off those boxes in your paper exam template and write your assessment and plan. Write full notes. (Don’t worry – I’ll tell you what to do with those notes in step 9). Don’t count on having the time to recreate it all later – you won’t. I spent an entire Saturday in the office getting back on track because I only wrote little shorthand notes and brief exam summaries, and then had to create the visit note once we were back online.

Step 4. Don’t try to do it all. Patients calling for non-emergent appointments should be asked by your staff (nicely and with profuse apologies) to call back tomorrow. Better yet, have your staff take their number and call them back the next day to schedule. Tell patients needing refills that you’ll get to it tomorrow unless it’s urgent. No point overburdening the staff and you at this moment.

Step 5. Manage the Spin. Make sure your staff notify patients in the office about what’s going on, so they understand if things seem a bit chaotic. No whining and complaining, just cheerful efficiency and mild jokes. Don’t lose track of what’s important – your interaction with the patient. When he/she leaves that day, they should remember that they were the focus, not the office systems.

Step 6. Don’t expect yourself to remember everything. If you can’t get read-only access to your patients’ online records, ask them to fill out a new patient history form in the waiting room before you see them. Since you’ll be running way behind anyway, it’ll give them something to do to feel useful while they’re waiting. I told my patients – “Pretend this is your first visit, and I don’t have your chart – because essentially, I don’t have it. So don’t assume I know everything about your medical history, and tell me anything you think I need to know. You won’t insult me.” No one complained.

Step 7. Don’t compromise patient care. If it’s not an emergency, and you’re uncomfortable starting a new treatment or medication without access to the record, don’t. Tell the patient you’ll review her record once you are back online and call her to finish up the treatment plan at that point. I did this with several patients, and was I glad I did – one woman had forgotten to note in her history form a condition which happened to be a major contraindication to the very treatment option we were discussing. I saw it immediately upon reviewing my records the next day and was able to switch gears with no harm done.

Step 8. Enjoy the down time. Take the time you would have used online checking email or writing consult letters to get to know your office staff. Maybe even order in lunch for everyone. And, since there’s nothing anyone can do once the last patient is seen, you all get to go home early. (That’s the best part…)

Step 9. Plan for an easy catch-up. Next day, when you get back on line, open up your visits from yesterday and write a (very) brief online visit note summarizing any info you’ll need later on to care for the patient. Have your staff scan your paper notes in to the electronic chart as support documentation, and you’re done.

Step 10. Check your charge interface. If you have a direct EMR to billing interface (we don’t – yet), check to be sure that no charges were lost during the down time. Charges from the previous day may have been transferring in at the time of the crash, or been lost during recovery.

Step 11. Learn something from the experience. As soon as possible, meet with your IT team to debrief and plan for the next downtime. Because you all know now that it’s going to occur again. But hopefully, not in the near future.

Step 12. Carry the message. If any of you have gone through a similar experience, and have additional suggestions, do drop a comment below. After all, we’re all in this together.

And, having had a spiritual awakening as the result of these steps, we must try to carry this message to other EMR users, and to practice these principles in all our electronic affairs…

Notes To Myself

What do you do with those little tidbits of information that you want to remember about a patient, but that you may not want to write in a chart for the whole world to see?

Case in point – A patient tells me her BRCA gene test results on the condition that I not put it in her chart. She paid for the test out of pocket, and is under no obligation to tell those results to anyone. I understand this, but if I don’t write it down somewhere, I won’t remember it the next time I see her.

In the past, this has not been a problem. I just put that information on a little stickie note in the chart. That way, it was right in front of my nose, but not shared if ever a copy of the record was requested.

The nature of my job means that I get told a lot of intimate stuff that relates to my patient’s gynecologic health. Perhaps there is a history of sexual abuse that impacts her ability to be examined. Or her husband is impotent, or has certain sexual needs that are affecting her. These details are important to our interaction both that day and on future occasions, but my patient’s insurer does not need to know then in such detail to confirm their medical necessity.

Simple. Just use a post-it! That way, if a colleague is seeing my patient for a related reason, I can pick up the phone and transmit the more sensitive information confidentially, sending over just the paperwork needed to care for the patient without blaring her personal life over the fax machine.

But now we have an electronic medical record, and my little post-it system is no more.

In the EMR, the only option I have is to make an entire encounter confidential, so that no other provider in our system can read it. I do use that option for the occasional celebrity patient or for the employees who wants their records uber-protected. But that does not work as well, in my opinion, for handling those little bits of personal information that count.

I wish so much that I were one of those doctors who remember every single detail about their patients, and rarely need to write anything down. Sadly, I am not. I can barely remember my wedding anniversary, let alone personal details about a patient I have not seen for months. I really do need these little notes to myself.

So, for now, it’s all going into the chart. (Or not, depending on just how sensitive the information is.) I’m trying to develop a little code system that will remind me, but that’s remains a work in progress.

If any of you out there using an EMR have tackled a similar problem, do tell me your solution.

Because if I don’t write it down, I will forget it. And that’s a promise.