jdenning Posted November 5, 2013 Share Posted November 5, 2013 2nd day in a row. Our IT folks are probably all having heart attacks. Can't get into any charts - can't review labs, can't do refills, can't do anything. I saw 12 patients yesterday flying by the seat of my pants and thankfully was able to come up with plans but will still need to do notes after the fact. This is getting unbelievably old. Link to comment Share on other sites More sharing options...
bradtPA Posted November 6, 2013 Share Posted November 6, 2013 We would use paper, and scan it into the EMR when it came back on line.... Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 6, 2013 Moderator Share Posted November 6, 2013 oh man, that is a bummer I was in a 12 provider practice and I had developed a single blank page visit form that would follow the patient from check in and then end up on my desk (or who ever saw the patient) Then once the EMR came up we would enter all the notes.... not pretty by any measure and lots of asking the patient hx and med list and other things that the EMR would have told me, but it was enough to get through the day.... sometimes even faster then the old EMR as you just treated what was in front of you..... Office staff needs to push back non-essential appointments... till the EMR is up again Link to comment Share on other sites More sharing options...
Guest Paula Posted November 6, 2013 Share Posted November 6, 2013 Isn't it interesting that after we get dependent on the EMR we can barely function? Somehow we develop a disdain for paper and pen and taking hand written notes. I'm one month into the launch of our EMR and today it froze........It FROZE....and I kept trying to enter the stupid prescription for omeprazole. Once it unfroze I had 5 prescriptions for the same med, couldn't figure out how to correct it. The EMR chart is a mess. I just shrugged my shoulders, said "oh,well" and went on the the next person. Our IT is in another state, one person for a 5 state Indian Health service area.......it'll be a long time before I learn how to fix mistakes. Thank goodness we haven't retired the paper charts yet!!!! Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 6, 2013 Moderator Share Posted November 6, 2013 welcome the sudden rush of productivity and freedom ? seriously, many emr systems I have worked with work best when they are down and we can go back to paper and dictation....:) Link to comment Share on other sites More sharing options...
jdenning Posted November 6, 2013 Author Share Posted November 6, 2013 Yeah, interesting. I've been with this practice 6 years and have never seen an EMR issue like this one before. EMR has been in place for several years - long before I got there - so not new. Yesterday I hand wrote notes for myself and did hand written visit summaries for the patients and made copies for myself so I would remember what we did....not looking forward to the slam of phone calls and refill requests though...not to mention the labs... Yikes. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted November 6, 2013 Administrator Share Posted November 6, 2013 Cancel appointments and go home. Can't see lab results, can't bill, can't review past chart notes, can't see patient allergies, can't e-prescribe... Can't run a clinic safely, let alone efficiently, with all that patient safety converted to electronics and then unavailable. Link to comment Share on other sites More sharing options...
mdebord Posted November 6, 2013 Share Posted November 6, 2013 Cancel appointments and go home. Can't see lab results, can't bill, can't review past chart notes, can't see patient allergies, can't e-prescribe... Can't run a clinic safely, let alone efficiently, with all that patient safety converted to electronics and then unavailable. I agree. Fortunately when our EMR goes out it's usually only about 20 minutes, but to keep the clinic flowing, I may have to see a patient on paper during that time. I am shocked at the adults that don't know which medicines they take, what they're allergic to, whether or not they had their gallbladder removed, etc. They always look at me accusingly when I ask because "it should be in my records." I haven't been in this game for long enough to tell - Do some of you feel the patients have sacrificed personal responsibility since EMRs became the norm? Link to comment Share on other sites More sharing options...
UGoLong Posted November 6, 2013 Share Posted November 6, 2013 I’ve been in practice for 7 years and it’s interestingto be living through the transition to EMR. We are something like the people who started with Windows 3.1 after years of DOS. The systems are still clunky and not as user-friendly as they will hopefully get. My practice started all paper and one of the LTACs I go to still is. Some hospitals are no paper, some have paper order entry and everything else is on line, and our office is mostly EMR these days. What I have learned from all of this is that the paper chart sucked. You often couldn’t find the test results you were looking for, read the last provider’s notes, or even sit comfortably while you tried to write with one hand while leafing through charts that opened in two orthogonal directions with the other. And forget it when you needed to refill 12 scripts for the patient. I love having an EMR, though I dislike specific features that hopefully will change over time. When we’re down (which isn’t too often), I do the best I can and we dictate the notes later. It’s not the best, but it reminds me of how much we have come to lean on EMR. Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 6, 2013 Moderator Share Posted November 6, 2013 Cancel appointments and go home. Can't see lab results, can't bill, can't review past chart notes, can't see patient allergies, can't e-prescribe... Can't run a clinic safely, let alone efficiently, with all that patient safety converted to electronics and then unavailable. nice in theory - but do you go home with our with out pay? As a practice owner there is no way I would send people home... lost income can not be made up...... also, we are not dealing with inanimate objects here.... we are dealing with people who can answer questions.... We are not in a field where we have the ability to "close up shop" and go home as you suggest.... my patients need to be seen and we have moral obligation to try (IMHO). What if we close and the swollen calf patient is not seen and dies of a PE the next day? Or the elderly male with reflux is not seen and not told to go to the ER for an AMI? Sorry but I don't have the luxury of closing shop - and we can and do work off paper.... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 7, 2013 Moderator Share Posted November 7, 2013 only folks who have never worked extensively with paper and/or dictations think an emr is more efficient. I have worked at multiple places that have gone through the transition. this is what happens every single time: 1.productivity in pts/provider/hr goes down by 50% 2.admin says once folks get used to it the productivity will return 3.it doesn't 4.admin double staff to see the same # of pts and says the emr is a big success. a place I worked 12 years ago went to epic. most providers there now have over a decade of experience with it. they still struggle to see 2 pts/hr with new, undifferentiated complaints when they used to see 4-6. if every visit is a bp check or rx refill in an established pt I can see the advantage of an emr. with folks who are brand new and need meds entered, complete social, hx, etc entered it is > 30 min before the nurses are even done with them and a provider can see them. it used to be they were in/out in 20 min total. Link to comment Share on other sites More sharing options...
UGoLong Posted November 7, 2013 Share Posted November 7, 2013 EMEDPA, I'm not going to argue with your experience, but to me anyway, being able to drill down quickly and get results on established patients is the bomb. And, when I'm doing a consult in a hospital, I like being able to remote in to our practice's system to retrieve records. That's a big deal for us, given that there are three different hospital systems (each with its own EMR), plus we do testing in our offices. That forgetful chest pain patient who might otherwise end up getting admitted for an unneeded stress test or cath gets to go home instead after an MI has been ruled out. That helps everybody. It takes a back room effort to make this happen and it does take more time to get a new patient into the system. We see most of our patients 3-4 times per year, so the initial investment ultimately pays off. The payoff, though, should probably be viewed beyond our own practice and include the patients and the overall healthcare system. In this vein, a big hope for EMR is cutting down on friendly fire incidents. I look forward to a day when EMRs integrate and it becomes possible to centrally manage a patient's medications. With people ping-ponging around between hospital systems and med reconciliation/patient communication being what it is, I get too many people coming in to the office with wads of paper from their hospital discharge, unsure of what they should still be taking. This is often at least partially because, on admission, they couldn't tell the hospital what they were already on. It's not always easy for an 85 year old guy with 7 providers to manage that by himself. The consequence is that now we've got a syncopal patient with a hip fracture because someone inadvertently added metoprolol to the unknown carvedilol that he was already on. I've worked around IT for years and IT is clunky and carries a large overhead. On the other hand, I've never seen such a data-intensive environment as medicine. It's clear to me that, despite the painful growing pains, we need more and better computer aids to do our jobs better. Maybe not you in your environment, but for many of us. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 7, 2013 Moderator Share Posted November 7, 2013 for established pts I concede the possibility of EMR efficiency. the vast majority of my pts in the e.d. are new to the system or have not been there for long enough that everything needs to be updated. it used to take 10 min to see someone with a minor hand lac, suture them up, and get them out the door. now it's at least an hr. Link to comment Share on other sites More sharing options...
Febrifuge Posted November 7, 2013 Share Posted November 7, 2013 ... My practice started all paper and one of the LTACs I go to still is. Some hospitals are no paper, some have paper order entry and everything else is on line, and our office is mostly EMR these days. What I have learned from all of this is that the paper chart sucked. You often couldn’t find the test results you were looking for, read the last provider’s notes, or even sit comfortably while you tried to write with one hand while leafing through charts that opened in two orthogonal directions with the other. And forget it when you needed to refill 12 scripts for the patient. Thank you for this. What so often gets lost in the discussion is the serious downside to an all-paper system. If you have a tight-knit group that isn't too large, and you can agree about best practices and the style of documentation, then maybe you can get something going that really is all positive. Far more often, though, you get truncated and nearly-useless notes, stuff gets missed, and coordination only happens when someone makes an effort. EMR has a million negative aspects, but it's not like paper is really some kind of golden age system that's been regrettably lost. Paper sucks. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 7, 2013 Moderator Share Posted November 7, 2013 my preference is dictation> paper. I can dictate an awesome note in 2 minutes with broad ddxs and explain my thinking for ordering each test,plan for f/u, etc. the same note on paper takes 5 min the same note in emr with a lot of free texting takes > 10 min. EMRs for emergency medicine are unfortunately set up for good billing, not good documentation. in epic you see notes based on the template that say "the patient complains of felling hot/cold in lower extremities for over 2 weeks for an uncertain time. this is a recurrent new problem worsened by nothing but improved by something". huh? Link to comment Share on other sites More sharing options...
Febrifuge Posted November 7, 2013 Share Posted November 7, 2013 for established pts I concede the possibility of EMR efficiency. the vast majority of my pts in the e.d. are new to the system or have not been there for long enough that everything needs to be updated. it used to take 10 min to see someone with a minor hand lac, suture them up, and get them out the door. now it's at least an hr. EMED and I are friends, but I feel the need to call bullshit. 10 minutes isn't enough time to clean and numb that hand, much less finish the repair. Put that aside, in the name of hyperbole, and there's still a larger point that UGo is making: In the old system, it might have been easy enough for you to do your thing in the ER, because your encounter was an island, right? You didn't know more about this person than you asked, or more accurately you didn't know more than they were ready, willing, and able to answer. The patient who neglects to mention a med he's actually on, or has a history that might have been nice to know about? Not really your problem. You practiced to the best of your ability, using established guidelines and evidence basis. And anyway, there was no possible way you could have known. That, I think, is where the EMR really shows itself as a double-edged thing. About 60 to 70% of the people I see in my Urgent Care have a PCP in that same building, during office hours. Being able to see what's up with their history, recent labs, have they had a checkup in the past year, what's been going on with specialists and etc has saved more than a few visits to the ER. The 85-yr-old who comes to me with vague complaints plus a huge med list (but they're not sure it's accurate), a list of comorbid conditions just as long, and oh by the way they see someone else across town who doesn't have records we can access is FAR more likely to be sent over to see you in the ED than the equivalent patient who has good stuff in the EMR, such that I know the heart block on EKG isn't new, and the meds have been tinkered with recently, and something just like this happened earlier in the year, or whatever. No denying that EMR is a huge pain in a lot of ways. There is probably a way to produce infinite data for many patients. But the advantages are real, and going back to paper scares the crap out of me. I see how sketchy some of that documentation is when providers have speech-to-text or unlimited typing space; how useful must their written notes have been? Link to comment Share on other sites More sharing options...
Febrifuge Posted November 7, 2013 Share Posted November 7, 2013 my preference is dictation> paper. I can dictate an awesome note in 2 minutes with broad ddxs and explain my thinking for ordering each test,plan for f/u, etc. the same note on paper takes 5 min the same note in emr with a lot of free texting takes > 10 min. ... Brother, you best be making yourself some Epic templates. I have a basic note that is gloriously bill-able and complete, plus it makes sense to read in English, plus it takes me 45 seconds to do. 90 seconds if I'm adding a paragraph free-text to the history. And I can use Dragon if I don't feel like typing. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 7, 2013 Moderator Share Posted November 7, 2013 EMED and I are friends, but I feel the need to call bullshit. 10 minutes isn't enough time to clean and numb that hand, much less finish the repair. Put that aside, in the name of hyperbole, and there's still a larger point that UGo is making: doh, called out!...ok, 15 min after the tech sets up the tray and irrigates the wound....:) Link to comment Share on other sites More sharing options...
Febrifuge Posted November 7, 2013 Share Posted November 7, 2013 That's why you're the Rockstar and we are the groupies, man. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 7, 2013 Moderator Share Posted November 7, 2013 Brother, you best be making yourself some Epic templates. I have a basic note that is gloriously bill-able and complete, plus it makes sense to read in English, plus it takes me 45 seconds to do. 90 seconds if I'm adding a paragraph free-text to the history. And I can use Dragon if I don't feel like typing. we have the 2012 epic asap with notewritter so the templates are already in there. that being said, the laceration template for example is a full page about what kind of consent, how you verified ID, what kind of diagnostic studies were done to r/o fb, did you do a time out, etc. the old note would have been: 2 cm L leg lac. anterior tibial region parq: betadine/lido 2% plain 4 cc, irrigated with saline, prepped/draped, no fbs seen in bloodless field, 5 # 4-0 nylon simple sutures placed with good cosmetic effect. EBL minimal. bacitracin/dsd placed. Link to comment Share on other sites More sharing options...
jmj11 Posted November 7, 2013 Share Posted November 7, 2013 nice in theory - but do you go home with our with out pay? As a practice owner there is no way I would send people home... lost income can not be made up...... also, we are not dealing with inanimate objects here.... we are dealing with people who can answer questions.... We are not in a field where we have the ability to "close up shop" and go home as you suggest.... my patients need to be seen and we have moral obligation to try (IMHO). What if we close and the swollen calf patient is not seen and dies of a PE the next day? Or the elderly male with reflux is not seen and not told to go to the ER for an AMI? Sorry but I don't have the luxury of closing shop - and we can and do work off paper.... ditto Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 7, 2013 Moderator Share Posted November 7, 2013 That's why you're the Rockstar and we are the groupies, man. nah, Davis is the rockstar. I'm just a guy who signed up early for the forum and posts late at night during slow shifts...I'm also a technology hating luddite. I'm working really hard in preparation for being a cranky old man someday: "damn kids, get off my lawn! darn hovercrafts, I remember when we had to put gas in cars and actually steer them, those were the days..." :) Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted November 7, 2013 Administrator Share Posted November 7, 2013 nice in theory - but do you go home with our with out pay? As a practice owner there is no way I would send people home... lost income can not be made up...... also, we are not dealing with inanimate objects here.... we are dealing with people who can answer questions.... We are not in a field where we have the ability to "close up shop" and go home as you suggest.... my patients need to be seen and we have moral obligation to try (IMHO). What if we close and the swollen calf patient is not seen and dies of a PE the next day? Or the elderly male with reflux is not seen and not told to go to the ER for an AMI? Sorry but I don't have the luxury of closing shop - and we can and do work off paper.... For people who CAN go back to paper charts, the decision becomes something along these lines: "Is the income I'll forego by not operating greater than the risks I'll take by running on paper?" Sure, patients can answer questions... but how many times have you met patients who don't know their meds or allergies? The moral obligation is to practice gold-standard medicine, and if you're converted to an EMR and that EMR is down, you simply can't do it. Don't sent the guy with chest pain home, send him to the ED! Swollen calf? Same thing! This will all be mooted by malpractice insurance--if I were in the medical insurance industry, and I'm not, I'd put clauses in all malpractice coverage that said that claims made for events occurring when an EMR was down would not be covered. Once they do that, and I expect them to eventually, it's not your choice any longer, is it? Link to comment Share on other sites More sharing options...
jdenning Posted November 7, 2013 Author Share Posted November 7, 2013 So I'm sure you'll all be excited to know that EMR was back up today but 36 hours worth of refills, phone notes and visit notes are GONE. Stuff I finished and signed on sunday is back on my desktop unsigned; and all the visit notes I got done on Monday are completely gone and will need to be re-done. Fortunately our staff all take notes while doing phone calls so a ridiculous number of hours went into re-creating those in new documents today. So there are now 84 extra items that need to be dealt with in addition to the visit notes from the last 2 days - oh what a joy it will be doing all this. Cluster&%&@ is the word of the day. Off to my desktop now... Link to comment Share on other sites More sharing options...
UGoLong Posted November 7, 2013 Share Posted November 7, 2013 I agree about the Epic templates. They aren't hard to make, especially if you take one that exists and rip out the stuff you don't want. We use ".progress" and ".consult" and then freehand the HPI and the plan, but in your case, maybe just the HPI needs freehanding. They make it fairly easy to add your own and decide if you want to share it with others. In a sense, you can consider the basic EMR system to be an operating system and you put applications on top of it. Using the barebones system, especially with templates you don't like, can be frustrating. Link to comment Share on other sites More sharing options...
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