PookieMD's Blog: Where Physicians Learn About the Business of Medicine

It’s hard to teach an old dog (me) new tricks, or to remember old ones.

The other night I was working the swing shift, and admitted a patient who I thought may have adrenal insufficiency.  Being the good internist that I think I am, I decided to order a cortrosyn stimulation test.  Being the creature of a habit that I am, I wrote “cortrosyn stim test at time o and in one hour” in the orders, not specifying the amount of cortrosyn.   There poor ward clerk was mystified.  “What do you mean, cortrosyn stim test–is that a radiology procedure?”

Spoiled creature that I am, used to simply typing in “cortrosyn stim test” in the computerized order entry system at the other hospital where I work–and having it spit out the protocol with out me looking up how much and at what times to give the cortrosyn and measure the cortisol levels.  All this got me thinking–do order sets make us stupid?  At my other hospital, where we have a complete electronic health record, we rely heavily on order sets and protocols.  This is all to improve care, but I think I have gotten overly reliant on them.

I had to go look up the dosing nomogram for the cortrosyn stim test.  I had a difficult time getting good results in my computerized search, and ended up asking a colleague, who, ironically enough,was ordering the same test and writing it in the orders.  I wrote out the whole protocol and turned it in to the ward clerk.

Sad as it is, it is probably a good think for me to have to slow down and write out orders. It makes me think a little harder, and that’s a good thing.

So you wanna have an EHR, do ya?  Well it’s not all about plug ‘n’ play, you know!  What does it take to successfully implement an EHR?  According to Biomedical Informatics edited by Edward Shortliffe (do not read unless you need to fall asleep!) there are five key factors associated with successful implementation.  Here they are, and I want you to look for the common theme.  Answer is revealed below!  (Hint: I added the italics.) According to Shortliffe, et al successful EHR imlementation depends on:

1. Organization leadership, commitment and vision
2. (the ability to) improve clinical processes and patient care
3. involving clinicians in the design and modification of the system
4. maintaining or improving clinical productivity
5. building momentum and support amongst clinicians.

Okay, so the quiz was easy. The bottom line to successfully implement or modify an exisiting EHR, you must have clinician buy in and support, and also improve productivity.   The ultimate bottom line: the EHR better deliver better patient care.

How’s your EHR stacking up?

I like to fancy that I am a good doctor.  I know I am good at reading, and particulary like to read old charts of the patients I am about to see.  The two hospitals I work at have EMRs, as do lots of the primary care doctors whose patients I help care for.  (No, I’m not going to rant on interconnectivity, although it’s tempting.)

No, today I am going to rant on two things: admission history and physicals, and discharge summaries.  Much can be gleaned from them, and at my two hospitals both theH&) andthe discharge summarey are  part of the EMR, EHR. (I’ve been told to refer to the electronic record as the electronic health record from here on, so I’m retraining myself.)  Anyway, much is to be gained from reading the discharge that your colleague so dilligently dictated or typed.  Like, your patient who had “heart troubles” and had that “normal test” actually had a stent placed and was told to take plavix, which the patient never picked up because it was too expensive. (Admit, you have all had that patient!) So, just from reading a one paragraph summary, you figured out the patient has known coronoary disease, and is at risk for re-occlusion because he had never picked up their plavix.  You look brilliant, but you’re not–you’re just thorough because you took the time to read the notes.

I love being the hero, especially when all I have to do is read the chart.  These days it’s even easier to get reliable information.  In the age of electronic health records, there is no excuse not to know what happened the last time your patient was in the hospital.  So stop you whining about EHRs and look like a hero.  (Now, if we could only link all of our various EHRs together…but that would be Nirvana!)

I have never heard a physician shout with glee, “yay, we’re getting an EMR!!!”

Physicians love to hate this latest technology, and for good reason.  Here’s why we hate ‘em:

• EMRs are comlicated.  When we had paper charts we wrote our notes on one side of the paper, and our orders on the other.  Quite simple.  If we had to read a note from a different doctor, we flipped through the pages.  (Hopefuly it was legible.)  We would open the tab to the lab results and look at them.  (Now, don’t forget that half the time you couldn’t find the chart!!!)
• EMRs are not intuitive.  EMR geeks have given us 10 different ways to do one thing.  We are simple souls– we want one way to do one thing. We wrote our orders on the paper and handed them to the ward clerk.  We don’t care about 7 different ways to order a lab test or medication, we just want to get it done.
• EMRs make us learn a whole new skill set.  We now have to “navigate”, and “cut and paste”, and use “smart phrases.”  We also have to know how to type.  This wasn’t part of our medical education, and we perceive it to take time away from what we need to do–take care of patients.
• EMRs make us feel like clerks.  When my hospital went to order entry, the clerks vanished.  ‘Nuff said.
• EMRs don’t mimic our work  flow.  When I work on paper, I take my note out, and have labs and other notes open on the table in front of me, so I can synthesize data and come up with a coherent plan.  EMRs make it difficult to mimic this work flow.
• EMRs don’t talk to each other.  There are a kazillion different EMRs out there that hospitals, offices and clinics are adopting.  Those of us that work at multiple different settings have to learn multiple different EMRs. 
• EMR  bulders forget that the EMR is a tool, not the end product!!! The end product is patient care.  The tool should be used  to enhance and deliver improved patient care.

You would think that I am a part of the anti-EMR faction.  Well, I’m not.  I’m a pragmatist.  EMRs are here to stay.  Make the best of it.   Be an influencer in a positve light–get involved to make EMRs better at your institution!

I am wearing a new hat–that of EMR consultant.  I wish I could say it has been going swimmingly, but, alas, I can’t lie.

It’s hard work, and sometimes I feel like a freshman in a graduate program.

I am in the company of a bunch of MBAs, techie types, and business wizards that use their blackberries like a third hand.  They talk the lingo, walk the walk and buy coffee together. Meanwhile, I show up, sometimes late if a patient is crashing, clutching my doctors lounge brew and a note book. I have had a big game of catch up to play as a lot of these folks have been working together for several years.

My biggest impulse is to try  to add something meaningful, such that I look like I know what I am doing. 

Wrong impulse. I called my dad, (thank god for dads!) who was an IT consultant in his time and a professor of IT. “What’s the best tactic for me to be valuable,” I asked.

“Listen much, and say little,” he responded.

Wow.  That sounds a lot like what I tell myself before I go see a patient.  Maybe I will get a hang of this yet.

In my gig as Dr. EMR, I went to visit a hospital where they are using a version of the EMR my hospital will be transitioning to. It’s an EMR I am familiar with, and I wanted to see how the docs were coping. Rumor had it that it was rough going, with admissions and discharges taking up huge amounts of time. I wanted to see for myself and get the truth. I think what we are told is frequently very different than what is reality.

So, here is my reality check on what was really going on:

Doctors were treating notes in the EMR like a blank sheet of paper: forget all the templates available, the macros, the short cuts. They were doing what they always did, and that was to create a note from scratch. Down the drain went the huge power of the EMR, replaced solely by the inefficiency of typing everything.

Physicians were (remarkably!) resistance to change: I was not there on a training mission, but every once in a while couldn’t help but ask—“have you considered doing it this way?” or “did you know you could do this?” while demonstrating a nifty short cut. Many of the physicians would say, “But this is the way I’ve always done it.” (Always being relative—they’ve only had the *$%# EMR for 9 months!)

Physicians not using available hardware: the hospital had gone to a large expense to purchase dual monitors so that notes could be up on one monitor, while the physician looked at reports/labs etc. on the other monitor and added to their note. Many physicians never bothered to explore the benefits of the dual monitor, which would have made the whole note creation process easier. This is likely a combination of lack of training and well known physician hubris.

Conclusion: training, training and more training is necessary when adopting an EMR, but teaching an old doc new tricks may be darn near impossible! Woof!

Just when you thought you had it down, you need another skill set–legal eagle.  Untangling the proposed rules by the CMS for meaningful use of EMRs is a challenge that would best the best of ‘em!  Here’s a quick and dirty take on the latest rules set out by the Center for Medicare and Medicaid Services EMR Incentive program, from Jan 13.

Points of interest:

• sections apply to both inpatient and outpatient providers/hospitals.
• EMRs must contain problem lists which CMS notes : “Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®. We believe the term ”problem list” requires additional clarification. We describe a ”problem list” as a list of current and active diagnoses as well as past diagnoses relevant to the current care of the patient. “
• EMRS should contain active medications
• EMRs should contain active allergies
• EMRs should have CPOE (!)
• EMRs must note if a patient smokes(amongst other requirements.)
• Patients must have access to copy of electronic health record
• Providers must have a way to share electronically with other providers.
• Providers will get incentive money based on the percentage of medicaid/medicare charges submitted by the physician.  Therefore, if you have a high percentage of medicare patients you will get more incentive money.

Wow! The last two requirements open a huge can of worms: the questions of  interoperability (how to share a record with a provider that doesn’t have the same EMR) comes up, as well as concerns for patient privacy.

What would I do if I was in the market for an EMR? Honestly, I would carefully examine the amount of medicare/medicaid patients my practice has.  If I had a large amount of these patients, and actively saw them, it may be worth while to go after incentive money to get an EMR.  However, if you have a small population of these patients, your incentive may be little to none. The entire program is slated to go away in 2016, with decreasing incentives available each year.  However, the incentives don’t get smaller until 2012, so it would pay to be diligent in researching your population and careful in your selection of EMR.

The CMS rules were tough reading.  Please let me know if you have a different interpretation!

Click here for the  link to the PDF from CMS.

This post borrows heavily from Attitude is Everything, especially chapter 9, by Keith Harrell.  The names have been changed to protect the innocent.

I am going to propose that there be a new ICD-10 code  for e/m of “changitis: the fear of change.”  (Don’t bother looking in the DSM for this!) Anyway, my hospital is going through a change with their EMR–a huge change, but inevitable.  I have observed the following  attitudes and behaviors from the physicians with whom I work:

Dr. Ostrich: “It won’t effect me because I never used the key functions anyway.” (Denial and as Harrell says, “a shift into neutral.”)

Dr. Eyeore: “This is horrible.  How could they allow this to happen? What’s with these people?” (Adopt a negative attitude.)

Dr. Wily Coyote: “Let’s start a revolution! Rally the forces! Ready the weapons! Let’s do everything we can to stop the change!”  (Adopt a counterproductive attitude.)

Dr. Welby: “Let’s make the best of it.” (Adopt a positive attitude.)

I learned something about change management from Mr. Harrell’s book.  As we all know, EMRs will become more prevalent, with the government mandated stimulus package to move medical care providers to use an EMR.  We can either cope effectively, or plan for an early retirement. Harrell suggests that we may not be able to prevent a change from occuring, but we can take positive action and make the most of it. We should acknowledge change, and seek to change threats into opportunities. So, when that EMR or new practice methodology or latest study on statin causes you to change the way you practice, try to embrace the change and make lemons into lemonade.  (Actually, make lemons in to margaritas!)

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I’m part of an effort to deploy an updated version of my hospital’s EMR.  It will be no small feat, as changes, they are a coming! There appears to be a smack down in the making over…(drum roll!)

The problem list!

One faction thinks that the problem list should contain, well, problems! This same faction also thinks that past medical history belongs in (I blush to say it!)…past medical history.  Ditto surgical history and family history.

The other faction believes that everything should go under the problem list, sort of a one stop shop.  They claim that this is one place where providers can get all the information they need, and that they shouldn’t have to update past medical history and the like.

Osler would role over in his grave.  What happened to the adage that most of the diagnosis was in the HPI and history?  What happened to the fact that past medical history was used to help diagnose and prognosticate? What happened to the fact that problems were things that clinicians were actively working on, and that past medical history was the past?

Putting everything under problem lists makes for muddled thinking and even worse, poor care.  If we can’t keep our thinking straight, than caring for a patient is all that much harder.  EMRs are only as accurate as their users.  If we can’t get it right in the EMR, it will perpetually be wrong.

Sorry, but it smacks of laziness on the part of providers not to populate past medical/surgical/family history. It is still an important part of patient care!

What do you think–do you take the fewer key stroke way (read lazy!) or do you go the distance?

If you are EMR shopping, there are several  basic considerations.  I’m not going to go in to the benefits of web hosted v. you hosted etc, who has bells and whistles, and gives the most screen shots.

Nope, lets cut to the chase and make sure you buy something you and your staff will use and love.  So here’s what to do:

• Get references.  Talk to everyone you know, and visit their practice.  Watch them do notes, order labs, and handle consults.  If there is lots of clicking, cutting, pasting, tooing and froeing, this is not the EMR for you!
• KISS! Keep it simple, stupid!  The idea is that if there is 4 ways to do one thing, you and your staff will get confused.  Try to find EMRS that have single, SIMPLE, easy to remember ways to do something.
• Look  for intuitive navigation.  Your hope is that your EMR operates intuitively, such that notes would be where you find notes, and the labs tab would be where you find labs.  Don’t laugh–your world is different from the IT people who created these EMRS!
• Watch for multiple opening windows and drop down screens.  The more windows you have to open, the more your screen fills up.  The more cascades open up as you click along, the more buried you get.  Your best option is a single click or command–going through windows and cascades takes time and causes frustrations to mount.
• Get complete buy in.  Shiny toys are fun, but think of buying an EMR like buying a house–you’re going to be in it for a long time!  Get all of your staff involved, and most especially, the physicians.  If they aren’t completely invested, you just bought the equivalent of swamp land in Florida.
• Train, train, train, and train some more.  A single class just won’t teach the users enough.  Plan on multiple, short sessions, with repeating lessons. 
• Be patient.  Rome wasn’t built in a day, and neither are competent EMR users.
• Know that you will see bad behavior.  One physician hand wrote his History and Physical and taped it over the computer monitor.  Nice.

Good luck out there!  Choose carefully, as the aftermarket resale value of an EMR is small, if non-existent.  (Can you buy an EMR on e-bay?)