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EMR Woes


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I experience the same frustration among medical staff (mainly physicians) at our facility. We have had a fully function EHR at our facility for a number of years. I haven't touched a paper record for nearly two years, and would never go back to hand writing chart notes and orders. The biggest issue at our facility is computer illiteracy among many on medical staff. This will not be fixed until generations of computer literate people are the majority among medical staffs of hospitals.

 

Issues of cloning ratty data are real, but easily dealt with by paying attention when charting. The answer is not completely illegible hand-written chart notes and medical orders. The examples about dictation are funny in this article, and not representative of how most hospital EHR work. Long before the EHR, I enjoyed reading folks "entertaining" dictations in hospital records.

 

We have a long way to go to improve the EHR, but the "promise" of the EHR (transparency, data sharing, error reduction, safety, etc.) is real and will be realized over time. A long time.

 

 

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THIS has been pretty close to my experience using 3 different EMRs over the last 12 years:

http://edwinleap.com/blog/?p=2504

in every incidence each dept has lost 50% of it's productivity and had to double staff to see the same # of patients. even a decade later at one facility they have yet to see the same # of pts/hr/clinician they did pre-emr.

EMRs are not designed for clinicians, they are designed for coders and administrators to show results they want to see, not the type of info which is helpful to clinicians.

My preference remains dictation or paper charts. fortunately, my primary job is still on paper. in 2015 we go to epic which I can use but prefer cerner or electronic t-system for ease of use. Today's 3rd generation epic is better than what they made us use at a prior job in 2000. that was a primary care program forced on the ER so every order was routine and had to be changed to stat. all rxs included 1 year of refills, etc

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Epidemiology is interesting to an epidemiologist. We start our EMR in October and it is based on the VA system. The physician and the RN who works with him are building all the templates. They are now our computer programmers and I am seeing most of the patients. It does not get any better than this of how resources are used to their greatest skills and abilities:;;D: in a tribal clinic.

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EMRs are not designed for clinicians, they are designed for coders and administrators to show results they want to see, not the type of info which is helpful to clinicians.

 

EMEDPA -- This is both true and not true. In Cerner, I love my customizable mView page, with all diagnostics, ancillary notes, consults, etc. gathered all in one place, with one click to drill down deeper and look at films, etc. This safes me a lot of time not having to root through a paper record, or switch to a radiology app, to get the information that I need to care for a patient.

 

I do a lot of specialty consults, and using Powernote in Cerner, I'm able to effortlessly gather a ton of data into the consult template that supports higher coding. This is especially true if I give the nursing staff time to enter in all the social, health history, meds, and health risk data. I also have taken the time to program in a number of macros as we say the same things over and over again on, for example, a surgical mandible. It is still not faster than dictating. The tradeoff is a higher level of coding is more easily justified and achieved.

 

In one area, it is faster. We see a lot of reconstructive patients back over and over again for procedures. Once I have a complete Powernote H and P in the chart, it is a matter of a couple of clicks to bring it forward, edit the HPI and plan, and sign it. It populates itself with current meds and updated procedure and social history. Much faster than dictating.

 

Medicine is changing, and much of the burden of documenting care is being shifted to the provider. This is hard for the older generations of providers who have not been brought up on computers. This is not the case for the present and future generations of physicians and PAs. All of my PA students come in with great computer skills, and on my rotation, they get a crash course in EHR as I make them do all my charting and order entry so that that are exposed to the EHR early. Most current and future students will likely never touch a paper chart in their careers; a major environmental shift in my lifetime, but the status quo for the future. We just need to make the transition more gentle and slow, and be tolerant of the folks that will never transition, many of whom will retire in the near future.

 

 

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If schools really wanted to produce competent clinicians....they would incorporate a class involving coding, meaningful use, conducting drug studies, business, etc...you know, real world stuff. Epidemiology is a waste of time.

 

We did have a one or two hour coding lecture, but I think I was one of the only students who was actually engaged. We did a whole lot of EBM, but nothing about actually conducting drug studies. We talked contracts & negotiations, but not business in general. We did not, however, do epidemiology. So, it sounds like real world preparation varies by school..

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We just need to make the transition more gentle and slow, and be tolerant of the folks that will never transition, many of whom will retire in the near future.

 

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what about the folks under 50 who hate EMRs and are fighting them tooth and nail and still have 20+ yrs left to practice? :)

Cerner for EM is ok as it flows nicely from section to section. For EM with no 2 patients really being the same the macros are less helpful. I can see how in primary care or a specialty practice these might be helpful. still takes me at least 10 min to do a complete note in cerner or epic and I can dictate a great note in 2 min.

I have learned how to d/c folks without completing the note but then work piles up. at some point all the notes need to get done and I am not willing to stay 2 hrs after my shift to do them so at some point I just stop seeing all but emergent pts and write charts and the dept comes to a screeching halt.

we are now 4 months into our epic conversion at one of my rural jobs and we have gone from waits less than 1 hr most days to waits > 3 hrs most days. length of stay and complaints have increased. we have gone from never using hall beds to having up to 3 fairly often. no one but admin likes the system and several docs already have quit because of it. and here is the scary part. I am probably the most competent provider on epic in the dept as I have used it elsewhere for > 10 years and I still feel that my productivity is down 50%. some docs have gone from seeing 20 pts/shift to seeing 8.

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It's all about design, the best EMR integration that I have seen usually involved a very customized version for the ED and some sort of dictation system. The docs and PA's at my last job seemed to really like Dragon for dication. Yeah the EMR still could be a pain at times, it was an older version of Meditech, but the hospital was very motivated in making sure it worked, so major issues were smoothed over quickly. Thus, things moved very smoothly in that ED and this was a Level I with about 120 patients on a average day, the limitation was often only space.

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Their will be HUGE consolidation in the next 5 years. Once the incentive money runs out their will be EMR companies going out of business every week! A few will remain standing and those will likely be the one's that are more capable....

 

I went with Practice Fusion as it has HUGE market share and is always upgrading their software - still pretty cumbersome in many ways, but getting better slowly

 

 

Medicine was the ONLY field where we literally have had NO technology advancement since the computer age started. Think about it - up till 5 years ago everything was still on paper! The airline industry was like this 50 years ago and they smartened up, now medicine is having to try to cram 50+ years of advancements into about 5 years.

 

It will get better (might get worse first but I think we are over the hump) and we will all be better for it. When I send a referral the note that goes is already FAR better then the hand written notes of old.....

 

 

What has to happen for it to truly be great is system wide intergration, so all labs, xrays, studies and other data all follow a patient - we do this already with most things in todays society and medicine just has to catch up.

 

I am in a local area where the only hospital system went electronic in 2002 - it is really really nice to look back at 10 years of lab data with a few clicks, the renal note from 5 years ago, the CT from two days ago..... it is really really nice!

 

Overall I think providers need to get over the "I can do it better then a computer" mentality and instead switch to 'if the computer HELPS me I can do it better with the computer...." BUT this means the computer has to help and not hinder.......

 

 

 

As for the stupid requirements on TAB versus CAPS I get this ALL the time and IMHO I think this should be a field removed from prescribing. It can be up the the PharmD to dispense which one is needed....they are smart people and we do not need to tell them how to do their job.

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Very interesting. It used to be that in a gathering of clinicians everyone would complain about their difficult patients; now all you hear about are the difficult EMRs! I agree that we will get down to two or three that communicate with each other, that integrate Dragon, etc. And having the younger PAs coming along will not hurt. Tongue in cheek if people know what I do for a living, but it used to be that when you could no longer do, you went into teaching. Now it will be when you can no longer cope with the EMR!!!! I guess that might be good with the proliferation of PA Programs :-)

 

Truthfully, you probably only have to be saved from one lawsuit by the availability of good documentation, both for your review when you are seeing the patient and for the review by the plaintiff’s attorney. Notes “in dictation” or unfiled in some distant satellite office , or the proverbial “lost chart” of yore helped no one. Communication difficulties (lack of info or the wrong info) were the one constant feature in the mistakes I have observed during my clinical career.

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We have Cerner with dragon incorporated, dictate anywhere in the note. You can mix macro, or use just clikcing with dragon, But it still takes 8-10 min to do a good defesnible (you hope) note. Some do notes in 5 min but use mostly macros. No dragon/dictation. Browsing hx on patients, some notes are so brief, you cant tell what happened. Yet how we can go faster, faster! Cerner has a lot of freezing, glitches, screen "flips" and suddenly your orders for Mr Jones, which you were in the middle of, are now partially Mr Smith's, kicks you out. Ugh!

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We go to four different hospital systems, each with its own EMR, plus one in our office (a different one). I started practicing before the current incarnation of each of the systems. The systems certainly aren't perfect and -- in spite of having a graduate degree in computer science -- it's hard for me to learn how to use all the neat features of each, so I'm not as efficient as I could be. We do dictate consults, but we do our progress notes in whatever system is at hand. Some of the places have computer order entry and some don't.

 

-We have Centricity in the office (not bad, but really more of an operating system on which you overlay your EMR application)

-We deal with Epic in one hospital (my favorite, I think. We quickly developed our own canned consults and progress notes)

-We deal with Orb at two other hospitals (not bad, but tests are organized by panels and not individual values, and the notes are designed for coders, not clinicians). And for some reason, nuclear stress tests don't have integrated final reports.

-We deal with Cerner at another system (my least favorite: the notes are OK but the order entry is clunky and constraining)

 

The big lesson so far is that I would much rather see a patient with EMR than without it, if only to be able to rapidly collect data from old tests and the like. I remember seeing office patients with a paper charts, trying to figure out what the notes from the last visit say, while hoping our staff filed their most recent cardiac testing in a place where I could find it.

 

I've never worked in such a data-intensive environment before and feel that medicine had to go to automated systems. There will continue to be pain as we do so. If they ever can get around privacy issues so we can get a patient's records from everyone with a touch of a button, we will be less likely to duplicate tests or overlook conditions and medications.

 

Many years ago I met an old guy who had been "a computer" in the digging of the Holland Tunnel, which was done from opposites ends and met in the middle. Every night during the dig, he and a bunch of other young guys would take data from the dig, determine the positions of the digging faces in the x,y, and z dimension, and then compute digging instructions for the next day. They stayed at it until their independent calculations agreed. Sometimes the sun was coming up when they finished. As a computer guy, I was intrigued, and more than a little amused. I mean, we wouldn't do it that way now, would we?

 

If one of my grandchildren decides to go into medicine,he or she will probably listen to my stories of paper charts and early EMR systems with the same perspective I had when I met that old man. A little patience is in order.

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