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

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?)

My time as EPIC “super user” is winding down, and I want to share a few observations.

Information Technology and clinical medicine are worlds apart, and bridging the gap is a major job.  I was in on a meeting where we, the clinical users, were requesting a change to the EMR.  What was interesting was how invested in our view points we were.  The EMR folks were in love with their product, and we clinicians were equally adamant about our need for an improved system.  Egos were also involved, as each party was passionate about what could and should be done.  Each party became more entrenched  “we’re working on it, but it’s a major build,” and then me, with my jaw on the floor, saying ,”but we need it fixed now!”

Oops. You don’t get too far with negotiations when your jaw is on the floor.  It’s hard to talk with your mandible on the carpet, and the flies can come in.   First of all, I put the IT folks on the defensive by my incredulousness at a process I considered unnecessarily complicated. I never was able to overcome my flabbergastedness (is this a word?) that my request was considered out of line.   I didn’t pay attention to the fact that the IT folks consider the EMR their baby, and by extension,  themselves.  I  came in with the assumption that of course I was right.

A stand off ensued.

With  out intending to do so, this conversation turned into a “crucial conversation” and I didn’t use the right tools to steer it to a win-win conclusion. Instead I walked out of the room, silently telling myself that what could I expect from people that live in a bat cave and never interact with anyone except other bats?

And guess what?  They thought the same thing about me.

Fortunately, those above me have better negotiation skills, and more power, so ego smoothing and problems solving insued.  Hopefully, next I will get it right, and check my ego at the door.

I am a “super user”–no, I do lots of drugs, and I don’t use people.  Instead, I am wearing a kelly green vest, and wondering around the hospital, helping the “go live” of EPIC at one of the hospitals where I work.  It’s kind of fun, really.  It’s a lot less stressful when a computer is crashing than when a patient is crashing!  However, operating in the business world of a hospital is much different than how we physicians and  medical types work.  Here is a smattering of observations about the massive undertaking of bringing an EMR into a large, well established, community hospital:

• There is a relentless focus on the positive.  At our thrice daily update meetings, the focus has been on what is working and how what is not working will be fixed.  There is NOT a lot of whining, or complaining on how stressful it all is, rather the focus is on the huge amounts of things that are going right.
• Gratitude and thanks are plentiful.  At our update meetings, people are constantly recognized for their achievements, asked what they need to get the job done, and what resources are needed.  
• A “can-do” attitude prevails.  Even controversial, challenging and technically complex issues have been met with a “let’s get it done” approach.  There is no one saying “it can’t be done”, but instead, “when can we get it done?”
• Extreme planning is evident.  Details were planned to the nth degree, with no item too small.  Round the clock reports are created, and we have status updates in the morning and evening.  It appears to me as if a great deal of resources has been poured into getting feed back from the various departments of the  hospital, and implementing changes to improve the system in real time. 
• Nurses, physicians, lab staff, radiology etc., were all trained far in advance, making the transition to electronic charting that much easier.  The advanced training is supplemented by masses of super users staffing every floor and department to answer questions and iron out glitches.

It makes me a bit wistful–what if my day was always filled with such positive attitudes, team approach, and “yes we can” thinking?  I think I would like medicine even more, and would find it a great deal more rewarding.  How can we apply these lessons to our day as practitioners?

Today I was covering in a small two doctor practice.  The patient population was largely female, and had problems scattered across the health care board.

The problems was, so were the records.

Each patient had a chart with appropriate blanks for a SOAP note, a check off scheme for physical exam and another blank area for the assessment and plan.  There was an area at the top where someone would check “meds unchanged.”  The problem was, when I went to look at the medication lists, there weren’t any. There was just a blank piece of paper where the doctor (or whoever!) was to list the meds.

But no one was doing that.  Many times I had to rely on the patients to tell me what they were taking, or reschedule the patient, telling them to bring in all their pill bottles.

In addition, I spent a lot of time leafing through labs, in one case trying to verify a clotting disorder, and a hospital work up.  Didn’t find either.

A pharmacy called, and I tried to verify a medication dose and couldn’t because I couldn’t find it.

This is the kind of stuff that causes duplication of tests, patient mismanagement and rising health care expenditures.  Yes, I have finally drunk the kool-aid, and feel that we all MUST have an EMR that communicates with other physicians, hospitals and pharmacies.  HOWEVER: I do NOT believe we should have 10 different EMRS that don’t talk to each other (kind of like our current health insurance, don’t you think?!)  I believe  we have got to have effective, efficient EMRS that communicate to all the arms of the health care delivery system.

But I’m not holding my breath.  So, if you need me, I will be leafing through charts trying to figure out exactly WHAT clotting disorder the patient has, and considering redoing the whole dang work up to verify it, and appropriately treat it.  Just how much will that cost?

The utility of an EMR lies in it’s utility.  Today, I heard about yet another practice that had paid for an EMR, installed it, and yes, you guessed it, had never used it!  Even more horrifying was the fact that this is the THIRD case of this I have heard in the last year!!! So what went wrong with the groups that purchased these unused EMRS?

They were deemed too complicated for use by the endusers- the physicians.

So what is the moral of this story? Due dilligence! And just to be sure sure, here is a short (and probably incomplete!) check list of buyer beware items:

• Make sure your office can affrord a good EMR. There is no cash for clunkers for EMRs!  Take in to account the initial purchase of the software, the hard ware required, the cost of IT upkeep and maintenance, as well as training.
• Involve the physicians in the decision making process.  Physicians, don’t you DARE sign off on something that you haven’t completely, thorough, painstakingly reviewed and researched!
• Make sure your office can afford the time it takes to train the personnel involved. Realize that office flow WILL slow down dramatically, and time per patient will go up.  Most EMRs, no matter how good, have a stiff learning curve.  Plan accordingly.
• Make sure your users are aware and accept that things will be slower and infinitely frustrating.  Don’t believe the reps when they say things like “office ready” or “easy” or “turnkey.”  Be realistic.  It will be painful.
• Have a super user.  Have one staff member, preferably a physician, learn the system way before it goes live.  That “super user” can then help the other physicians with their head aches, belly aches and gripes.  Physicians seem to handle input better when it comes from a colleague, rather than a medical assistant who now appears much smarter than the physician.
• Have enough computers to work off of.  Not enough workstations=no implementation.
• Failure  is not an option.  Commit to using the EMR from the get go, and don’t let anyone weasel out.  If your practice is making this step, it’s like a Catholic marriage: divorce is not acceptable.

So, commit!  Life in medicine is hard enough without an expensive, useless purchase.