EPtalk by Dr. Jayne 12/3/20

I’ve received quite a bit of feedback and comments on my recent Curbside Consult that addressed ongoing usability issues in EHRs. Some of the comments came with questions, so I thought I’d answer them here because the answers raise other interesting items for discussion.

The first question was around why my organization controls access to the vendor’s documentation and/or why I cannot access it because I’m a physician informaticist.

In my clinical practice, I am not a physician informaticist. I’m a frontline ER/urgent care provider, just like the other 100-odd providers who are employed by my organization. I play the role that the majority of physicians and healthcare providers in the US also play – we are simply gears in the machine. It has been made abundantly clear that our collective role is to see patients, follow organizational directives, and not ask a lot of questions. This is not unique to my organization, but also applies to many emergency physicians around the country, a good portion of whom are employed by third-party companies and not the hospitals or facilities they serve.

Back in the days before COVID, I made a couple of suggestions about the EHR – implementation of features that I know must exist because they were required for 2015 CCHIT Certification and this is a Certified EHR – and was told that it was not my concern and that leadership needed to focus on operations and not chasing down issues with the EHR. They apparently don’t see the links between happy users and productivity or good workflows and patient safety. Like many other mid-sized organizations, they do not see value in paying a physician good money to perform non-clinical work. Our EHR is maintained by a paramedic who is “into computers” with occasional input from the chief medical officer. I see this mindset all across the US, including at a major academic institution where I was on faculty.

Many institutions still do not see value in clinical informatics. This lack of understanding is the primary reason I became a consultant. Don’t think you need a CMIO? Fine, hire me for an engagement and I’ll convince you why you need one more than ever. To those who work at hospitals and health systems that place value in clinical informatics leadership, be thankful. It isn’t like that everywhere. Culturally, my organization would rather curl up and die than bring in a consultant that might tell them they’re not perfect, because they think they are the best and most tremendous care delivery organization on the planet and say it regularly in pep talk emails to the staff. Hyperbole is alive and well there, as is penny pinching.

Another question addressed why I won’t name an EHR when I talk about its flaws.

As a consultant who has seen the good, bad, ugly, and downright horrific, I am reluctant to throw a vendor under the proverbial bus for the sins of its clients. I used to do subcontract consulting work for a major EHR vendor. They would send me out independently to troubled clients. My only responsibility was to figure out what the issues were and craft recommendations that would help get the clients to a happier and more productive place.

Invariably, shadowing one or two patient visits would reveal a poorly-configured EHR that didn’t take advantage of the vendor’s latest features. Some clients were so far behind on upgrades they were no longer able to receive support, but they were unprepared to even consider an upgrade for various reasons. Operational and leadership pathologies contributed to never being able to optimize the EHR. I’d love to be able to get a demo-grade copy of our EHR to know how good or bad it isn’t, but until I know it’s the EHR’s fault and not that of my myopic leadership, I’m not going to blame the vendor. If I had unfettered access to a general release copy of the EHR that I knew had not been butchered or gutted by a client, I would be more than happy to name and shame.

I enjoyed David Butler’s comment about “God came in and created Intelligent Medical Objects.” IMO is one of my favorite add-ons for EHRs that don’t already have it. My current EHR as implemented does not leverage IMO. There is some kind of mapping among ICD-10 and SNOMED and ICD-9 (which we still have to use for certain work comp cases), but it’s mediocre at best.

I also enjoyed the comment from AnInteropGuy talking about systems that still ask if someone has had overseas travel, since that’s currently a somewhat moot point. I recently had to take a family member for dental care and assisted them in filling out their COVID pre-screening. Question #1 was, “Have you recently traveled to China or traveled on a cruise ship?” I kid you not. Those questions are so March 2020 and indicate a vendor who can’t be bothered to stay current or a client who refuses to upgrade.

Thanks to all who commented or reached out by email to either Mr. H or me. I enjoy hearing from readers and being able to understand where you’re coming from.

Many of my physician colleagues are taking all kinds of unproven supplements — including aspirin, melatonin, zinc, and vitamin D — in an effort to either stave off COVID or reduce its severity should they become infected. To be honest, healthcare providers in my area are dropping like flies. I strongly suspect lack of appropriate PPE. Some nurses have been wearing the same N-95 masks since February because their hospitals say their role doesn’t demand anything more than a surgical mask even for COVID-positive patients, and even the best-provisioned of us may get one new mask a week despite the fact that the new CDC recommendation says masks should be discarded after five “donning” cycles, which equals one day if you eat lunch and hydrate a couple of times during your shift.

A few of my more fringe colleagues are also taking prescription drugs like ivermectin (which will also keep them free of heartworms and cat scabies) because there are a couple of papers that say it might be a good idea. I’m personally on board with a new study that links consumption of chili peppers to better midlife survival.

The research was presented at the virtual American Heart Association 2020 Scientific Sessions. It concludes that higher intake of any type of chili pepper was associated with fewer deaths from all causes (including cardiovascular disease and cancer) during a seven- to 19-year follow-up in middle-aged adults. As any good student of the middle school science fair can attest, correlation does not equal causation, but at this point as a physician looking down the barrel of a rampant and seemingly unstoppable pandemic that many in the US still believe is a hoax, I’ll take any positive thoughts I can get.

Having spent time pursuing my studies deep in the heart of Texas, I became a fan of the chili pepper. Since then, I’ve been on enough camping trips to know that a splash of hot sauce can help overcome many a bad meal. As an added bonus, daily consumption will also tell you if you still have your sense of taste and smell and whether you need to take your “essential worker” self for a COVID test, since many of us are exposed regularly but never tested.

What’s your COVID prevention regimen? Leave a comment or email me.

Email Dr. Jayne.