EPIC Go-Live Day! And a prayer for wisdom…

Some dear friends of mine, at Busy Community Hospital, are having a momentous day.  Today is the ‘Go-Live’ for their brand new, shiny EPIC EMR.

For those of you outside the hallowed, creaky halls of medicine, EPIC is one of the most widely used electronic medical records systems in America.  It’s big, it’s expensive, it captures lots of data, integrates ER’s, hospitals, clinics, labs and everything else.  (Probably your cat’s shot records too.)

EPIC is also a company highly connected to the current administration; big donors to the President.  FYI.

The problem isn’t what you get out of it, it’s the cumbersome way you have to put it in.  In my opinion, for what that’s worth, EPIC is not intuitive. It takes a long time to learn to use it well.  I have never used it in a situation where it could be fully customized, but I’m told that makes it easier.  And admittedly, some docs and nurses truly love EPIC and are at peace with it.  I suspect they have implanted brain chips or have undergone some brain-washing.

https://giphy.com/gifs/zoolander-ac38RqTgQXYAM

Typically EPIC instruction occurs over weeks, as it has for my friends.  The first time I used it was in a busy urgent care, which was part of a large medical system.  And I learned it over one hour. On the Go-Live day.  So I’m sympathetic.

Thus, I have a prayer for those in the belly of the beast right now:

A Go-Live Prayer for those with new EMR systems.

Lord, maker of electrons and human brains, help us as we use this computer system, which You, Sovereign over the Universe, clearly saw coming and didn’t stop.

Thank you that suffering draws us to you.

Thank you for jobs, even on bad days.

Forgive us for the unnecessarily profane things we have said, or will say, about this process.

As we go forward, we implore you:

Let our tech support fly to us on wings of eagles and know what to do.

May our passwords and logons be up to date.

Protect us from the dreaded ‘Ticket’ submitted to help us.

May our data be saved, not lost.

Let the things we order be the things we have.

Shield us from power loss, power surge, virus and idiots tinkering with the system.

Give our patients patience to understand why everything takes three hours longer.

And may our prescriptions actually go to the pharmacy.

Keep us from rage and tirades.

Protect the screens from our angry fists.

May everyone go home no more than two or three hours late.

And keep our patients, and sanity, intact.

Great physician, great programmer, heal our computers.

Amen

 

 

 

 

 

 

Some new, important screening questions for the EMR

Scrolling through FEEMRS (you know, Fancy Expensive Electronic Medical Records System), I was stricken by just how much data is on the chart.  I mean, it’s pretty dang amazing.  But I was, simultaneously, reminded that most of it doesn’t help me.

It helps someone, mind you.  For instance coders and insurance companies.  The complexity of EMR also helps those who track our car to door, door to chair, chair to chair, chair to bed, bed to bathroom, bed to X-ray, request to blanket, request to sandwich, request to TV remote, request to ice chips, complaint to Dilaudid and discharge to angry times.  (The really important stuff!)

But so often, FEEMRS just gets in my way.  I mean, I struggle to find little things like triage information, medications or last menstrual period. And as for visual acuity?  Faggettaboutit!

However, I do think there are some things that might be useful screening questions.  So, here are a few things I think we should have the nursing staff ask on the way into the ED.  I mean, we always ask about drug abuse, interpersonal violence, immunizations, sexual activity, whether or not the withered 98 year old has lately traveled to any Ebola infested exotic locales.  But is it really enough to know if the newborn has stopped smoking? Or are there other more interesting things with which we could further clutter the hallowed screens of our FEEMRS?

I hereby suggest:

What is your preferred pronunciation of the only pain medicine that ever worked for you?  With what letter does it begin?  (Incidentally a patient recently pronounced their favored drug ‘Laudy-dah.’  Awesome.)

What unfortunate thing has lately happened to your medication?  Eaten by dog, stolen by neighbor, smashed by meteorite?   Hey, it could happen…

Is there some species with which you identify and would prefer to be treated as?  Because if so, we may need to call a vet. Or tree surgeon.  (It’s no joke.  Tree-kin is a real thing…I mean, ‘real’ thing.)

First thing that pops into your mind when I say ‘outstanding warrants.’  Go!

What is your favorite kind of sandwich to eat while waiting on your psychiatric commitment.  Just kidding. We have Turkey.  (It’s empowering to offer a choice even if we really don’t have one.)

This is to be asked immediately on arrival into triage.  Right now, how long do you believe you have waited to be seen? One hour, two hours, three hours.

Do you know the patient advocate’s name and phone number?

For abdominal pain:  Please tell me what kind of cheeseburger, chicken sandwich or friend food you have consumed on the way to the ED, and when you finished….oh, you’re still eating it.

This is very useful and instructive: Why are you on disability? With a few mental health exceptions, if it isn’t evident in triage, it will be a good story.

How many times have you been committed to a state or private psychiatric hospital? If the number of suicidal commitments is greater than ten, patient can probably go to the waiting room.  Especially if eating cheeseburger and suffering from simultaneous abdominal pain.

Is there a particular physician you would like very much to see or not to see? Or want to hurt?

Full disclosure.  What are you here to get, and if you had it, you wouldn’t be here at all?  For instance, work excuse, pain medication, etc.

Who told you you should come to the ER, if anyone:  your physician’s office, your attorney, a police officer, your sister’s best friend who is a CNA at a nursing home, or a 24-hours health line?

Do you find it difficult to stop playing video poker on your phone while talking to a clinician?  

Will you please eat these chips and fill out my satisfaction survey while waiting to come back?

Just scratching the surface.  Send me some of yours!

edwinleap@gmail.com

 

My Most Important Patient

Medical stethoscope on keyboard as symbol for administration and office

Listening for heartbeat of most important patient

 

This was my column in the March edition of Emergency Medicine News, as linked below.

http://journals.lww.com/em-news/Fulltext/2016/03000/Life_in_Emergistan__The_Most_Important_Patient.13.aspx

My most important patient requires my constant diligence. For this reason, I am seldom far away from him. Only a few minutes inattention and there will be problems. I cannot forget my patient; I am trained to attend to him constantly. I am a professional, and my patient is, ultimately, my customer and the customer’s service is paramount, I am told. I am reminded by policies and procedures as well, and there are those who will contact me, day or night, regarding failure to do what my most important patient requires.
In these 29 years since I started medical school, I have seen many wounded and sick patients of varying degrees of complexity and interest. Legions of fevers and columns of colds, tribes of chest pains and nations of bruises, entire cities of coughs, herds (as it were) of nausea and vomiting and battalions of sprains. Flocks of fractures and entire civilizations of chest pain. But none of them, not one, occupied me like my most important patient.
I was guided by teachers in urgency and priority, I was taught to hurry here, take time there, but always be attentive. I was shepherded by wise physicians before me, but never did any of them put a patient on a pedestal the way my most important patient has been. Neither snakebite nor sepsis, aneurysm nor arterial blockage, pneumonia nor parasite has ever been thrust before me as the most important patient…until now.
What could he have, you ask? What affliction? Who could he be? Of what importance? Celebrity? King? Judge or politician? Child of my own? Parent or priest? Hardly. Not one, not even captains of industry who endow hospitals, have the power of this patient.
This patient, this most important patient of all, stares back at me all day long. I examine and treat him with my hands and sometimes my voice as I stare intently back into his face. I wander off to other ‘patients,’ but all pale in comparison to this one. He violates all privacy and priority and knows absolutely everything. I see a chest pain next-door, or a pelvic pain across the hall; a weeping suicidal woman a few rooms down. I come back and tell my most important patient each secret. The sordid or tragic details of every life I whisper to him, or write upon his screen.
Once my hands loved examining other ‘patients;’ the shape of normal and injured bone, the sound of clear and diseased lungs, the nuance of stroke, the tenderness of the abdomen that took so long to understand. Now I have no time. I must touch my patient, enter the password and let my well- trained fingers run across plastic, not skin or bone. Or speak into his ear with a microphone, far more expedient than time wasted with others. Far more important and billable.
Every time I wander away, my most important patient calls me back; ‘hurry, hurry, tell me about the others! Don’t take too long!’ And others humans, more important than I am, remind me. ‘Don’t neglect your most important patient! Finish everything he needs as soon as you can! He is the key to all of our money! And if you don’t, we will fine you, or punish you in some other way for failing to care for the most important one of all! But make sure the flesh ‘patients’ are happy; give them a little time or they might be upset and not come back, and then what will you tell your most important patient?’
My most important patient is now everyone’s most important patient. He (or perhaps sometime she) is in charge. Sometimes he is shy and recalcitrant and will not wake up, will not look at me with his glowing eye. When that happens, nothing can happen. No orders for labs, xrays or medicine. He is an angry god, and when he is angry no one else can be happy. Sometimes he is confused and plays pranks on me, so that what I thought I said to him is turned on its head or made unintelligible. He is capricious that way; but ultimately far better than ‘people,’ who say and do things that my most important patient isn’t programmed to understand or record. He doesn’t like that, and forces me to do things in a confusing manner because he is angry.
And he is a time miser; he wants all of my time and those who brought him to me (or rather brought me to him, a kind of sacrifice) know that he is greedy and yet expect everything to run as before, when other patients were important.
But I know, and you know, those days are gone like electrons on a wire. Because now, the most important patient of all takes the most time and the most effort and the most diligence because data and billing and tracking and policies are what he does and his handlers love those things the way we used to love humans. And spoiled as my most important patient is, I believe it is unlikely that anything will ever be the same again.
Pity. Humans are interesting. But sick or well, they simply cannot stand in the way of data entry.

FEEMRS: Fancy Expensive Electronic Medical Records System

I was at a locums assignment yesterday using FEEMRS. (You know, ‘Fancy Expensive Electronic Medical Records System?) It was all kinds of busy, with wait times of many hours. And as I slogged along, relearning FEEMRS after a few weeks away, I realized that it takes about one hour of looking at that screen for me to become exhausted.

It’s just too ‘busy.’ Every bit of the screen seems filled with some data, some field, some time-stamp. Oddly, I struggle to find the triage note, the home medications, the history. I struggle to find whatever orders I have entered and to see if they have been completed. I throw my hands up trying to discontinue orders and I nearly weep when it’s time to discharge a patient, a process which takes far too long with various orders, time stamps, discharge instructions, medicine reconciliations, printer selections and all the rest. Honestly, it’s far easier to admit someone to the ICU than to discharge them. At least in terms of computer time.

That’s the thing about FEEMRS. The ‘flow’ is all off. Oh, it’s data rich. But it’s mentally exhausting. Too many clicks, too little useful data, not nearly enough ‘white space.’

Furthermore, there are the orders to sign and the charts to sign. And after you’ve signed them, there’s another place to sign. And if the nurse so much as helps them to the door, and enters that fact with appropriate time-stamp, ‘0300, touched patient on elbow at door,’ well it’s going to need another physician signature to validate the elbow touching event and document that it was necessary, approved and billable.

Docs using FEEMRS across the country are daily beset by hundreds of orders that require signatures the next day; things we didn’t even know were orders. ‘Placed bandaid.’ ‘Paged nursing supervisor for admission.’

A friend of mine was asked to sign nursing orders for psychiatric meds (Psychiatric Meds!!!), placed by nurses for hold patients three days after he went off shift. He wisely refused but was told ‘its OK, everybody does it’

By contrast, this year and last, I worked at TMH (Tiny Memorial Hospital and its several campuses) where I (gasp!) used paper charts or dictated to a human transcriptionist. My patient’s meds were either in front of me or one flip of paper away. My discharge instructions were a check mark away, or three clicks on a different program. And often, for orders, I check a box and handed it to a secretary to enter into the system. In some instances, my prescriptions were written by hand (not perfect) and could be ‘deleted’ or ‘reconciled’ with a simple tear of the paper.

I notice, now, that when I go back to my hotel room after working with FEEMRS, I sleep poorly. No wonder. I’m clicking and looking, scanning screens and logging on and off until 2 am. I tell my kids to stop looking at screens before bed or they won’t sleep well. I keep it up till the wee hours.

FEEMRS is quietly, slowly, electronically killing all of us and making us less concerned with patients than we are with fields, files, clicks and saves.

Something has got to be done…

I just do n’t know what.

The doctor will show compassion after he’s finished charting

I was working in a hospital recently and saw a note from a CEO on the computer. Notes and memos are ubiquitous these days. Bathroom walls, break-rooms, computer screens. Everywhere there is another reminder to check this, do that, mark those, record metrics, hurry up, don’t make mistakes, sign orders, complete charts, be nice and all the rest.

But this note stood out. In it, the administrator was reminding the medical staff that their job was tolerance, compassion and understanding. I’m not surprised by this. I’m aware that some administrators make ’rounds’ in patient areas and assess how things are going. (Concerns about HIPAA seem irrelevant, as I mentioned in a recent post.)

It seems, in a kind of ironic inversion, that the business side of medicine has tasked itself with telling the medical side how to be nicer doctors, better doctors, caring doctors. I’m not surprised; but I suspect it isn’t due to any collective epiphany about medical professionalism. Ultimately it’s really less about patient satisfaction, that Golden Egg that drives almost everything in medicine now.

But the irony runs deeper. While the CEO can hold forth on lofty, but important themes like understanding and tolerance, while various administrators can stroll through the ICU or various units shaking hands and making nice, physicians are doing something else. Lots of something else.

In the emergency departments where I work, physicians scurry out to see patients then run back to chart. And chart. And chart. And in many instances to sift through the endless possibilities of ICD-10 codes (I recently saw ‘2nd degree burn due to water skis catching on fire.’). Sometimes we are expected to code in more detail. Discharging a patient is, itself, often a complex process filled with orders, searches, clicks, signatures and locating the right printer.

I recently worked at a site with a shiny new nationally known EMR. ‘Please call the hospitalist,’ says I to the secretary. ‘Alright. Will you enter the consult order in the computer so I can document it?’ I’ve been handed faxes to fill out myself and of course, nothing gets done until it’s ‘put in’ the computer. Another rant for another day, as I digress.

The physicians rarely look up from their keyboards to chat, except when running off to see the patients who inconveniently stand between them and their real job of data entry, billing and coding. All done real time. If you don’t do it, by the way, you’ll get e-mails or texts the next day about your unsigned orders. ‘The coding department needs these right away.’

There was a time of collegiality. There was a time when we discussed cases and our feelings and our sorrow and our passion. That was when medicine was about people. Remember them? The upright primates on whom we practice medicine? Now? Now it’s about numbers and billing, metrics and tracking, satisfaction scores and rewards…and punishment.

Little wonder the CEO can round, or hold forth on the intangibles that lured many of us to love medicine in the first place. Physicians aren’t physicians anymore, not since we handed the reigns over to administrators so that we could ‘focus on the practice of medicine.’ And not since billing became so complex in order to justify every pen stroke, every bandaid, every pillow fluff. And not since the growth of administration, which has itself dramatically increased costs just as it has in universities across the country.

I want us to be tolerant and caring, compassionate and kind. But it’s hard to do when your entire job is less about humans and more about business. It’s hard to do when the volume of patients explodes thanks to unforeseen consequences of the ACA, the endless beatdown of EMTALA and the unending medicalization of everyday life. It’s nearly impossible when you’re tracked like a Caribou for every action and every key-stroke. It’s hard to do when there are no rests, no pauses, no coda in the great dance of emergency, or any other, type of care.

I often work in small, slower places. I do it in part because I can sit and talk. I can breath. I can think. Heck, I do it because I can act like a CEO.

Medicine is great. I love my work. But that’s the thing. I love my work. My real work. Meeting the sick and injured, figuring out what’s wrong, sifting through truths and untruths, danger and anxiety, solving problems.

I don’t love the slavery of modern medicine, which will be the same whether it is run by corporations or government. (So don’t kid yourself that nationalized care will solve this problem.) Governments and corporations are virtually interchangeable anyway.

Perhaps worst of all, I don’t like seeing my colleagues, young or old, as the joy escapes from them shift by shift, only to be replaced with exhaustion and bitterness. Or fear of some unknown repercussion from some faceless manager who leaves takes an hour lunch every day and leaves at five.

Maybe CEOs need to be lectured on how to have compassion and understanding towards their physicians and nurses. I think I’ll start rounding in their offices.

And writing my own memos…

A chart should tell a story. (My EM News column for March.)

 A Chart Should Tell a Story. 

My EM News column for March.

 

http://journals.lww.com/em-news/Fulltext/2015/03000/Life_in_Emergistan__Tell_Me_a_Story.6.aspx

 

 

I suppose it is obvious that I am a fan of stories. I like to hear them, read them, watch them, collect them and tell them. I believe I am participating in stories every day of my life. The story of my family is a beautiful epic. The stories I hear at work can break my heart. One of my favorite stories starts like this, as told to me by an adult man in his forties: ‘The thing is, me and my mama live with her boyfriend. And the other night, her boyfriend had a cardiac arrest! And when he had the cardiac arrest, he rolled out of bed, and crushed the Pomeranian.’ I can tell it better in person.

Obviously, story is truly essential to medicine. The history we obtain from patients is a story, a narrative of the development of whatever affliction they are facing. The medical record we generate is a larger version of the story, which includes past conflicts and resolutions, various antagonists and protagonists, symbolism, sub-text, conclusion and all the rest.

The problem is that in medicine, we have murdered the story. But it isn’t a complicated mystery. The murder occurred because the modern medical record is designed to gather demographics, monitor (and modify) our behaviors and generate bills. Therefore, it must be easily interpreted by people, or computer programs, that look for clicks and checks rather than descriptions. After all, it takes time and training to learn to read and appreciate a well-crafted story. But not so long to do a word-search.

I suspect that it is also a generational issue, as younger physicians have grown up with communication shared in short bursts, whether on television, in music, while texting or using various forms of social media. So I suppose that I understand how we have evolved, or perhaps devolved, in our medical communications.

In all fairness one can ‘reassemble’ the story from click boxes and drop-down menus. It just takes effort. It certainly requires more time than it would take to read a story. It’s rather archeological in nature, in fact. One must look at the nurse’s notes and the time-stamps, the triage vital signs and the things ordered, the timing with which they were ordered and interpreted, the consultations, the disposition, the prescriptions, the out-patient tests. All of it, when properly put together, can give an approximation of the who, what, when, why, how and where of the encounter.

But what we often do not have, particularly in times of crisis when the patient suddenly returns, is the luxury to put the pieces together again. Nor do the consultants and primary care doctors and specialists who see our patients later and who very much want to understand what transpired. And yet, as I travel around, and as I look back on various charts to discern what happened on previous visits, I see check boxes, labs, findings, diagnoses (often vague) but no description. The ‘Medical Decision Making,’ or ‘Emergency Department Course,’ are empty fields. In years past, we were told that these were critical parts of the chart that showed the complexity of our thought processes. I suppose EMR has changed that, on some level. But I’m think we’re worse for it. Looking at those particular blank spaces is like listening to crickets in a field. Or staring into an empty room. The absence of words doesn’t help anyone; least of all the patient.

So let me take this moment to encourage everyone to leave a note, even a wee, little note, describing what transpired in that patient encounter. Fine, if it’s strep throat, if it’s an ankle sprain, I get it. I can figure that out. But for anything with the slightest complexity, anything requiring several labs, or studies or consultants, please tell me a story!

It needn’t involve a ‘dark and stormy night.’ But it should have enough information to help the next person reading it. ‘This 14-year-old girl has had two weeks of intermittent cough, fever and shortness of breath. She has a negative chest x-ray but was noted to have scattered wheezes. She was feeling much better after an Albuterol treatment and her parents agree to arrange follow up with her doctor next week.’ It’s not ‘For Whom the Bell Tolls,’ but it’s a nice, simple summary that helps everyone else to have a sense of what happened. And it did so in three, count ’em three (3) sentences!

Chest pain? Summarize it and describe the plan. Trauma? Tell me why they were safe to go home. Headache? Explain, however briefly, why it wasn’t necessary to do more work-up. Heck, make it a game! A kind of ‘micro non-fiction.’ (Micro fiction can be a story as short as six words.) Diligence at this craft makes us more effective, more succinct communicators. And in the press of modern medicine, that can only be a good thing.

When my children were little, bedtime was always accompanied by this question: can you read a story? I’m just asking a similar thing of my colleagues. Before you put the chart to bed, write me a story.

And if it involves a Pomeranian, so much the better.

Hospitals should pay for charting time

Pay clinicians for their EMR time!

nurses-charting

 

I have a unique perspective as a physician.  Having traveled to many hospitals in the past two years, working as a locums emergency physician, I can comment on a variety of issues with a reasonable amount of experience.  One of those issues is EMR, or Electronic Medical Records.  I have spent plenty of time writing about this in the past, and I will continue to do so.  Because all across the country the same problems, the same frustrations are evident.  And the institutional lack of concern is well-entrenched and well understood by everyone affected.

Whether working in an academic teaching/trauma center or a small community department, one theme emerges.  EMR is so inefficient, and patient volumes and acuity so high, that charting isn’t done real-time.  Unless it is accomplished with scribes, or by dictation, doctors stay after their shifts, or chart from home, or come in on their days off in order to complete their documentation.  Needless to say, this is unlikely to create the best possible chart. Not only is this true, I have watched as nurses sat for one to two hours after their busy ED shifts, catching up on the ever increasing documentation requirements in their EMR systems.

Weary from a long day or long night, they sift through notes and charts, orders and code-blue records, trying to reassemble some vague estimation of what happened in the chaos of their 8 or 12 hours on shift, when they were expected to function simultaneously as life-savers and data-entry clerks.  Further, the nurses are frequently tasked with entering specific charges for billing as well.  It all constitutes an unholy combination for any clinician.

Dear friends, colleagues, Romans, countrymen; dear politicians and administrators, programmers and thought leaders, this is unacceptable. Entirely unacceptable. If the charting system is so poorly designed, and so counter-intuitive to the work we do that it can’t be used real-time, then it should be replaced with something far better.  And if it isn’t replaced, then everyone needs a scribe to chart for him or her, or we should allow dictation all around.  And if none of that is acceptable, if even those reasonable options are rejected, then every nurse and every physician who stays after shift should be paid their regular hourly rate for time spent charting. The thing is, these systems are generally not the idea of the clinicians who are saddled with them.  They are imposed by corporations and administrators who believe the salesmen and hope to capture more billing and data. They are imposed by the ‘Meaningful Use’ regulations of the Federal Government.  But as a rule, when we clinicians say a system is bad, or won’t work for us, we are patted on the head and dismissed.  ‘It’s fine, it’s an industry standard.  You can learn to use it.  You don’t want to be a problem doctor do you?’

One of my friends is in a group shopping for new systems.  When his partner asked to take the potential EMR for a ‘test drive,’ the salesman said, ‘sure, as soon as you sign the contract.’  Pathetic. I call on everyone involved in implementation of EMR to find the simplest, most physician and nurse friendly systems possible.  And to do it by asking and involving the end user.  By which I mean those who provide patient care, not those who cull through it for billing and documentation. Some people chart more slowly than others.  That can be an individual issue. But when a system consistently causes good, efficient doctors, nurses, NP’s and PA’s to stay long past their shifts, or come in on days off, or chart from their homes (which should be places of recuperation and rest), then we need to give them something back.   Equally toxic, some physicians and nurses can only get out in time by charting in a manner that results in a pages long list of check-boxes, rather than a descriptive, informative story.

America’s emergency departments are overwhelmed with passwords, required fields, clicks and key strokes, at the same time as they are overwhelmed with the sick and dying. They are the last safety net for the uninsured and underinsured. They are the point of rescue for the poor, the brutalized, the traumatized, the addicted, the psychotic.  Day in and day out, nurses and physicians in emergency departments, indeed all over the modern hospital, do their best against sometimes overwhelming odds.  In the midst of this, poor charting systems constitute a crushing blow.

Pay the staff for their time spent charting, or fix the systems.  Or both. But something has to give.

Edwin