Curbside Consult with Dr. Jayne 12/19/11

I really struggled with what to write about for this week’s Curbside Consult. I thought about being witty or trying to come up with some clever HIStalk version of “Twas the Night Before Christmas,” but the things I saw today top anything I could ever come up with. So listen, dear readers, to the cautionary tale of why each and every one of you who work in health IT can never forget the importance of your role, whether large or small.

As you may have picked up from my columns, when I’m not in the CMIO trenches, I work in various clinical environments. I don’t have to (it’s not part of my contract,) but I discovered during a year-long sabbatical from patient care that I really did miss taking care of people. I missed the simple joys of being able to make a new parent confident that their baby will eventually sleep through the night or helping patients come up with a plan to manage chronic health conditions. I missed the patients who came to me with lacerations because they knew I could patch them up faster than the local emergency room.

I did not, however, miss dealing with insurance companies, RVU compensation models, and administrators who didn’t know beans about running a medical practice.

When I was ready to see patients again, I had to find opportunities that wouldn’t interfere with my CMIO duties and that were flexible enough for me to still have plenty of time to cultivate my hobbies (can one really consider martini drinking a hobby?) I chose to be a non-employed physician. Sometimes I work for a staffing company, covering urgent and emergent care facilities. Sometimes I work as a locum tenens to cover docs who are on medical or family leave. Today was a little of both and to compound the “perfect storm” that was brewing, it was a place I hadn’t worked before.

You know you’re in trouble when you pull up to the designated employee parking garage and it’s essentially a chain link cage with a badge-swipe entry portal that looks like a sally port. As a last-minute fill-in for a physician out on leave, I didn’t have a badge, so I had to phone a security guard, who had to find my name on a list. Of course they didn’t have me on said list, but I must have looked fairly non-scary, so they buzzed me in.

I parked (next to a Corvette and a Jaguar, safe in their cage – go figure) and headed in. The staff was friendly and I had enough time to get fully caffeinated before the patients started rolling in, both of which are usually good signs.

The Emergency Department Information System (EDIS) was one I had worked with before, so I was pretty confident that I was going to be able to roll along without incident. Boy, was I wrong. Today was a veritable textbook of “lessons learned” on what can go totally wrong with software, hardware, and workflow. As I mentioned, this is why it’s so important for everyone who works in health IT to take their jobs seriously. Information Services leadership take note and hold on tight, because here we go:

1. I was given a stock password and told to change my password the first time I logged in. Unfortunately, my security classification doesn’t permit password changes, requiring me to call the help desk, which told me I could tell them what I wanted and they’d load it on their end. Really?
2. Better yet, the PACS system has a generic login and password left on a sticky note taped to the monitor. When I asked about this, I was told they had gone to a generic login because the doctors couldn’t remember their passwords. I can’t imagine what their HIPAA audit policy looks like for figuring out who viewed what data with generic logins.
3. To make things more exciting, the IT team scheduled a planned upgrade of the financial and registration system during the day shift. There were no printed downtime procedures available for staff and no clear communication plans. We were alerted to upgrade status by random people who would walk through the ED shouting “it’s back up” or “it’s down again.” Eventually we figured out that the patients whose names appeared in mixed case were registered using the integrated system, and patients whose names were all lower case were manually registered in the EDIS. That might have been nice to know since those manually registered patients had no outbound orders stemming from their accounts. We figured this out after radiology never showed up to do films on our patients – apparently we were supposed to call radiology to schedule those manually registered patients.
4. I’m usually obsessive about hand hygiene before and after touching patients. Today I actually felt an uncontrollable urge to wear gloves to touch the keyboard. You may have noticed I said “keyboard,” as in singular. There was one computer for me to use in a 10-bed emergency unit and it was a fixed desktop. That means no documenting in a patient-facing manner, thereby leading to rework, possible memory errors, and potential transcription errors. The nurse also had a single fixed workstation. Interestingly, the registrar had a really nice new computer on wheels (wireless) to go with their spanking new financial and registration system. So much for enabling patient care.
5. The software had not been updated to a Meaningful Use-compliant version. Not that being MU certified has anything to do with usability or efficiency, but it has become at least a minimum standard for software to meet. Basic demographic information is required to meet MU and this system had some major holes. I know the vendor has a MU compliant version (I’ve used it before,) but this was not it. The users were unaware of any planned upgrades.
6. I’m fairly certain the EDIS was not JCAHO compliant or remotely adherent to the precepts of the Institute for Safe Medication Practices, either. For prescribing, it was almost entirely hard-coded with physician “favorites.” Unfortunately, many of these favorites included “do not use” abbreviations as well as medications that have been off the market for several years. Users told me the prescribing system was hand-built and doesn’t import data from any of the respected formulary vendors. It was pretty clear no one was updating it, either. There was no appropriate way to prescribe current weight-based pediatric prescriptions. In order to get a non-ambiguous medication order for the pharmacy, I had to find the closest “canned” medication I could then print it on safety paper, finally crossing out the confusing parts and handwriting a traditional script below to clarify the confusing computer-ese. To the pharmacists on the receiving end – mea culpa, I didn’t know what else to do.
7. There was no ability to save any kinds of defaults or templates when documenting patients. I had the choice of either a “brief” history/ROS/exam, which was basically a canned jumble of findings (which I’m sure some committee somewhere worked really hard to agree on, rendering it individually useless) or the ability to check each individual finding box individually. After a full complement of ED patients, I’m seeing individual checkboxes when I close my eyes.
8. Customizations had been placed into the system without logic, resulting in duplicates and user brain fatigue. Most of the follow up clinics were listed as “Clinic – Specialty” but every now and then I’d see a rogue like “Derm Clinic” (even though Clinic – Dermatology was in there) but there was no consistency.
9. Clicking for Spanish patient education materials occasionally printed documents in a language which was distinctly not Spanish. Thank you, Señor B for gently educating the gringa that the discharge instructions were muy mal, because you’re right, I didn’t look at them before I handed them to you or I would have known. Shame on me and my apologies to those who taught me during eight years of Spanish classes.
10. Printers were non-configurable. I could print the discharge summary for the patient, but when I wanted to print additional information (such as sources of free medication for uninsured patients), my only choice was “print to file.”

I could keep going but I won’t. Hopefully you get the point.

As an outsider, the confluence of all the various decision streams at work here created a veritable maelstrom in which we tried to deliver care. It would be tempting to refuse to go back if I’m ever asked to staff that facility again. What’s interesting, though, is that I probably won’t refuse if I’m called. Why? Because the patients were genuinely needy, the care provided was solid despite the challenges, and the staff worked their tails off as a team to get through the shift. Everyone did his or her part and then some.

By the end of the day, it was like we had worked together forever. Hugs were exchanged (as well as recipes for Christmas cookies and empanadas – thanks for introducing me to things I never thought possible with chocolate and coconut) and high-fives given. I learned a nice trick for removing the proverbial rusty nail from the bottom of a foot, courtesy of a provider who shoes his own horses in his spare time. I did a little bit of education on Meaningful Use and information security.

Last, but most important, I helped some people. And that, my friends, is what it’s all about.

Feliz Navidad, próspero año y felicidad.

E-mail Dr. Jayne.