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Readers Write 3/24/2010

March 24, 2010 Readers Write 9 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Digital Information is Great, but Only if it’s Accurate
By Deborah Kohn

I am a patient at two local healthcare provider organizations that use the Epic suite of clinical information system modules for their base EHR. Both organizations must not yet have installed Epic’s CareEverywhere because currently, the two Epic systems do not talk to one another (or even look / act like one another). But with time, the installation of CareEverywhere should occur at both.

However, the reason I write this article is that either there is a flaw in Epic’s MyChart, the organizations do not know how to correctly configure MyChart, or there remains an important Epic user training issue. When I visit my providers at both organizations, I receive a hardcopy summary of my visit, which I must assume gets generated by MyChart because also I can view the data online via MyChart. Among many items listed on the summary are Current/ Future/Recurring Orders.

1) Orders listed on the summary and in the system cannot be corrected easily by an organization user, even the provider. I don’t know whether this is a user training issue (e.g., how to easily DC or cancel electronic orders that have been performed but, for some reason, not automatically canceled as Future Orders), a system flaw, or a poor implementation of the function. But for one set of lab orders, I was repeatedly asked for lab work to be performed when the lab work was performed months ago and I had the documentation to support this. Unfortunately, it took several handwritten notes and phone calls from me to the provider to finally update and delete the already performed lab orders from the system.

2) If orders listed on the patient’s hardcopy visit summary are incorrect (e.g., numbers of milligrams, duplicate orders, q 4 months not q 2 months, etc.), again these orders cannot be easily corrected by an organization user. That’s because, according to the organization’s users, these orders come from a different “database” than the “real” orders, which are correct in the system, but don’t print to the hardcopy correctly!

3) Either the Epic clinical system does not include or the provider organizations have yet to install or know how to install the following clinical decision support function: Recently, when my provider at one organization ordered a routine TB test, there was nothing in the system to alert the provider that the same, routine TB test was performed at this organization in July 2009. Consequently, this test was repeated in February 2010 at a cost of $398. When I complained about this, the provider organization commented that it is the provider’s responsibility to look back at all the orders in the system to see if a TB test had been performed within the last several years. I don’t blame the provider for not wanting to scroll through several years of past orders to determine this. And I was sorry I didn’t have my “paper” PHR, which I have kept for at least 30 years, with me at the time to double check this.

Now that electronic PHRs and visit summaries are appearing and patients are beginning to “use” (indirectly) organizational EHRs, not only will the organization’s internal users be complaining about system flaws, poor configurations, or outstanding training issues — but external users, the patients and recipients of health information exchanges, will be added to the lists. Consequently, it’s time our industry professionals address the management of the information, not just the technical and operational mechanisms for the sending and receiving of the information. Because it’s great to receive digital PHRs and visit summaries from provider organizations, but only when the information is accurate! Just ask ePatient Dave!

Deborah Kohn is a HIM professional and power user of EHR systems who not only makes sure her analog and digital health record information is correct, but remains dumbfounded that she need not do same with her bank record information.

We Are In the Business of Letting Clinicians Treat Patients
By Jef Williams


While riding the shuttle to my hotel at HIMSS in Atlanta, I overheard two strangers behind me comparing stories of the conference to one another. Their short exchange encapsulated for me both the HIMSS event and the climate in which we are now living. The conversation went something like this:

Woman: “I attended a session today conducted by an IT expert. You won’t believe what I heard”

Man: “Really?”

Woman: “Oh yes. The presenter was talking about successful EMR and IT implementations and actually said, ‘The physicians are the ones who have received the education. They are the ones who treat patients. So they must be the focus of our implementation.’”

Man: “You’re kidding.”

Woman: “No! I was so offended I nearly walked out.”

Man: “That’s ridiculous.”

Whether one agrees with the federal stimulus package and the push toward EHRs, the fact remains that it has created a significant impact on the business of healthcare IT. Clinicians, administration, and IT each play an important role in running the healthcare organization. Administration and IT serve, however, in support roles to the mission of providing an environment that allows clinicians to do what they do best: treat patients.

Over the past decade, the role of IT has grown significantly as healthcare has played catch-up to the most other industries in moving away from paper and manual systems to electronic and automated systems. This shift has had its share of challenges and most organizations can list a number of tragic stories of failed or messy implementations. Difficult workflow, poor user adoption, and meaningless data are all symptomatic of the problem of letting IT professionals make critical decisions sans clinical input regarding system procurement, design, and implementation.

It appears we have not learned our lesson. Introducing federal subsidized funding and reimbursement into the business model of clinical information systems the federal government has shifted focus to management and IT, leaving clinicians in the trailing position. The idea that caregivers come last could not be more backward to the true value proposition of healthcare. This industry is, and will remain, primarily about providing healthcare. No matter how advanced EHRs, widgets, and handheld devices become, patients will continue to measure satisfaction by whether a doctor knows what she’s doing, has the right tools to treat, and that they ultimately are healthy.

So to that presenter at HIMSS, I am not offended. It seems in this climate we have forgotten that we are in the business of letting clinicians treat patients. No EHR, HIS, PACS, eMAR, or any other system can provide better patient care without a doctor reaching out a stethoscope and asking her patient to breathe deeply. We in administration and IT get to play a valuable role in providing the tools and support to help our physicians provide better patient care. But we are just that — support.

Let’s not let the promise of a few dollars and the lure of a few vendor-hosted parties blind us to that fact.

Jef Williams is vice president of Ascendian Healthcare Consulting of Sacramento, CA.

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Currently there are "9 comments" on this Article:

  1. 1) Lab orders placed/ordered in Epic may or may not be electronically interfaced to the Lab where you went to get the work done. To complicate things, even if they were correctly sent to the Lab software, depending on user workflow and interface design the results from that Lab software may or may not make it back into Epic (mainly because they don’t match correctly on account number or patient identifiers). Thus, a manual workflow is needed or a batch could be used to get rid of the future/pending Lab orders from Epic…

    2) It depends on which version of the EpicCare Ambulatory software is installed, but modifying a patient’s current medication list (dose, frequency, strength) should be a common workflow for providers. That said, no medication reconciliation workflows in Epic seem to be easy or straight forward until the most recent releases of their software.

    3) Sounds like duplicate order/therapy checking may not be configured, that said – I can remember the last time someone inserts liquid under the skin of my arm and I’d be sure to remind them not to do it, if not needed.

    I can’t agree enough with the last paragraph, I find it painful to watch many providers use EHRs as a patient, realizing the system can always be implemented better and end-users trained on more features.

  2. Hospital users would not typically be doing anything in MyChart except looking at their own charts. Answers to the points:
    1) Your provider needs to be kicked in the butt. And since orders are legal entities, other users would likely not have the security to change them. Fairly typical.
    2. See above. Staff are going to be in the live environment unless they’re in downtime.
    3. From your description, it sounds like you ran into policy, not lack if functionality setup. As is common, lots of organizations turn off clinical alerts. Those organizations who use lots of clinical alerts have doctors who on’t page through pages of alerts. Alerts tend to be minimized to very important, usually missed items. Your provider should be looking through the tests anyway.

  3. PLEASE read/listen to Debbie Kohn’s comments. She’s REALLY smart about this stuff and highlights that murky territory between vendor software capabilities and implementation in the real world.

  4. @Hansen
    I submit that while there is functionality that can be tweaked to work this functional requirement into place it should be the vendor placing it into the model system. Unless an exposure event occurs the typical TB test would be yearly.

    @The world in general
    Sitewide EMRs have historically been setup without worry of costs or best practices. The prevailing theory being that “Client” Hospitals will assign the clinical/billing staff to evaluate and put in place those types of associations. Essentially, our current systems do not try and take into account clinical care so much as provide a place to store that data. The vast majority of the Vendors currently selling EMR’s have little to no incentive toward educating their own employees toward these goals as their turn over is so demonstrative that they would essentially loose all capital invested into the process. Regardless of the intelligence of the employee you cannot cram in the requirements of receiving your MD, RN, or even CPA while having them work 50 hours a week. The change will not come from vendor sites, only when the healthcare systems demand a product that is supported by professionals who have more than a 3 month crash course in the software system and lingo used in healthcare will we see a change.

    @Jef, Impassioned plee, I wish we would see every hospital implement a yearly “physician shadowing” plan for all their back office employees. When staring at databases and code day in and day out its easy to forget the true impact of what we’re doing.

  5. Deborah. Very well done.

    This just goes to show, you can spend millions on software. But if it’s poorly implemented (as your providers is) it can make life hard.

    In fairness not all the problems you wrote about are bad implementation. Some are training. These issues are well known by anybody who has been working with EPIC for a few years. If they had experienced people helping them implement they would have helped them with this.

    The moral of the story is you need good people on your team… still.

  6. Well said, Deb—“However, the reason I write this article is that either there is a flaw in Epic’s MyChart, the organizations do not know how to correctly configure MyChart, or there remains an important Epic user training issue.”

    Take your pick or select a component of each, you will be right. That this stuff is allowed to be sold to unsuspecting health care providers is despicable.

    There was a picture of a sign posted on this blog last week about Medwatch. The author should call the number and report her complaint to the FDA.

    Hey, Mr H and Inga, put that picture up again. I can not get back to it.

  7. woman: “Oh yes. The presenter was talking about successful EMR and IT implementations and actually said, ‘The physicians are the ones who have received the education. They are the ones who treat patients. So they must be the focus of our implementation.’”

    Man: “You’re kidding.”

    Woman: “No! I was so offended I nearly walked out.”

    Glenn Beck has a term for these type of people:

    Dummy dum dum.

  8. Yes, quoting Glenn Beck tells us you are enlightened. Is there ANYONE dumber yet more dangerous than that dummy dum dum?

    Political preferences aside, why quote a certified lunatic in response to a dumb statement.

  9. Deb Kohn brings up some very good issues…and it ain’t jsut Epic.

    Now tell me again how spending $20 billion is going to solve this problem?

    Oh yes, it’s ‘meaningful use’…the hospital has purchased a ‘certified’ system – but who has the time and money to dig that deep to see if it is really meaningfully used??
    Looks like we’ll have to spend another $20 billion on auditors.

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