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Hats Off to AMDIS
By Ann Farrell
Congratulations to AMDIS for saying what many of us believe and promote, but had feared was falling on deaf ears or been drowned out by politics and ego. It’s not surprising that the “Boston Docs” known MD-centric view of the world (healthcare and IT) produced a largely MD-centric, “CPOE first” meaningful use strategy. Hopefully this attitude was rejected when Version One of MU was sent back to the drawing board the day after the first draft was issued.
Chasing ARRA money already put some hospitals on a dangerous path to drop everything in hurry up mode to “install” CPOE without examining physician workflow, decision making, cultural and change management needs, and foundational applications. Some EMR companies and their advocates encouraged this — some unwittingly, others with an eye on increased or accelerated quarterly revenue recognition, the metric vendors are held to (incented by), particularly public companies.
For CPOE to be more than an automated requisition generator, MDs need to get tangible value, including the ability to make better informed decisions based on more timely data (not meaning the computer is making decisions for them). Since ancillary systems were ground zero for hospital clinical automation, lab and X-ray results are almost always online before or with CPOE.
What may not be present is assessment data entered by nurses, ideally at the point of care in near real time, e.g. allergies, height/weight, vital signs, I & O, nurse-collected lab values, and an accurate medication record. That is critical data for clinical decision support (CDS) for MDs in ordering. Not having these data available wastes MD time and steps and results in suboptimal or even unsafe ordering decisions. If data is not easily retrievable (preferably “pushed” to MDs in the ordering process at the right time), physicians are forced to look for paper charts, call for information, chase nurses down, or make ordering decisions without important or current information.
In addition to providing a clear path to CPOE, automating the eMAR/BCMA has greater potential impact on med error reduction than CPOE. Not killing or harming patients would seem a primary goal to improve quality of care. MDs and RNs make approximately same number of errors, but pharmacists or RNS catch 50% of MD errors downstream whereas 98% of RN errors reach the patient. And, nurses work for hospitals and are more easily corralled (in theory), thus making clinical and business sense to start with foundation pieces first.
Hopefully Drs. Glaser and Halamka (and Blumenthal) are listening. Some have recommending staging implementations as if it’s a pecking order — doctors first! To be effective, CPOE needs to be part of a bigger strategy –patient-centric, outcomes (not IT) focused, with staged functionality and a 21st century interdisciplinary care team approach that respects all caregivers’ roles and contributions.
For the good of all, we want CPOE to be embraced by MDs, but also for MDs and US healthcare reform to be more inclusive and patient-centric. I speak as clinical consultant, former EMR vendor exec, and RN who worked with first commercial EMR in a hospital with near 100% CPOE in early 1970s. CPOE is hardly a new phenomenon, yet some MDs and vendors act as if it started with them. We’ve known for decades how CPOE can be implemented successfully. Now’s the time to really get this right.
Ann Farrell is a principal at Farrell Associates of San Francisco, CA.
An Alternative Desktop Standard
By Mark Moffitt, MBA, BSEE
We have deployed a unique desktop configuration at our healthcare provider organization. The configuration is a Mac-mini running Windows 7 release candidate (RC) with a 17” wide-screen monitor.
The advantages of this configuration over a conventional PC are:
- Smaller footprint
- Less expensive
- Higher quality hardware
- Better cloning capabilities, i.e. ability to clone the windows partition using the OS X operating system
- Run Leopard and/or Windows 7
We skipped Vista as a desktop standard. We found W7 RC to be very stable. So, rather than install XP on newly deployed machines, we opted to deploy W7 RC. Once W7 is released, we will install it over W7 RC.
The cost of the Mac-Mini, display, and keyboard and mouse was less than the conventional PC configuration we were considering. Your mileage may vary.
Power users in IS run both Leopard and W7 RC. They are both really good operating systems. Leopard is much better working with multimedia, while W7’s sweet spot is “corporate computing.” I run both on my MacBook Pro.
Mark Moffitt is director of information systems at Good Shepherd Medical Center of Longview, TX.
Physicians Using PCs
I think you need additional inspiration!
Seriously, I think you’re confusing the work flow of an office based physician with the work flow of an inpatient physician (i.e., hospitalist or critical care specialists as examples). We (hospital-based physicians) spend much more time sitting down, sifting through and analyzing data (whether in electronic or paper formats) than we do with hands-on patient care. That’s NOT because the data analysis pulls us away from the bedside, but rather it is the bulk of the work: analysis, married with the patient visit and examination, tempered by experience and judgment, aided by decision support as available, leads to action.
Why do computers in patient rooms fail to attract physicians? We want to work at a desk, adjacent to our colleagues, where we can sit and work without being distracted by what’s going on in the patient’s room. Doesn’t matter whether we’re working from a computer record or a paper record.
And BTW: the “pecking away at a keyboard” has made me a vastly more efficient and informed physician than when I worked off of paper. Lawyers have the option of turning the work over to “associates”. In the absence of medical students, the patient gets the full attention of the “partner”! Score one for physicians.