EMR

EHR-a doctor/CMIO’s perspective

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Dirk Stanley wrote this in reply to a post on http://radar.oreilly.com/2009/11/converting-to-electronic-healt.html

I felt it needs to be heard.

I can only say that no matter what we do from a technical standpoint, a lot of medicine isn’t ready from the cultural standpoint.

Medical culture is a weird creature, that not a lot of people understand. (I’m sure Glenn above can attest to this.) Docs, historically, have been used to people “compensating for them”, for example :

1. A doc writing a script for Percocet (1) tab PO QID PRN instead of Percocet (1) tab PO q6h PRN pain.
2. A doc writing for “regular diet” instead of “Regular diet, dysphagia level I, nectar thickened liquids.”
3. A doc having weeks to co-sign their verbal orders.
4. A doc writing “Vanco 1gram IV x1 STAT” instead of “Vancomycin 1 gram in 250mL 0.9% NS run over 2 hours at a rate of 125mL/hour”
5. A doc writing “Heparin protocol” in the pre-EMR world, versus an electronic order for “Heparin protocol” where *all of the teammembers know what to do*.
6. A doc choosing an EMR because “It’s the best for me” versus “It’s the best thing for my patient”.

These are the hidden implementation costs. Training docs to think along these lines is important, but nobody has a clear training plan on how to change this medical culture.

This is why, some people look at OpenVista as the solution – IMHO, putting OpenVista into a private hospital will not produce the results it does in a VA hospital. Docs need to understand there will be compromises, and they need to buy-in to those compromises, before any migration to EMR will work.

Technology only works if the culture supports it.
I can tell you there are still a LOT of cynical docs out there who are quick to try a solution, and if it doesn’t work the first time, they lose faith.

Again, I wish things were different, but as a practicing physician who sees a lot of different medical computing environments (ICU to private office), I’m really concerned about the implementation plan here.

Finally, I agree, we do need an EMR Czar, or a “rockstar” who will talk about these things openly to help change the culture to be more supportive of technology. The problem is that to talk about it openly would mean having frank discussions that a lot of people don’t want to hear yet…

– Dirk 😉

RECs, HIEs, & EHRs: Curiouser and Curiouser

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Here’s a response I wrote for a very interesting conversation started by Andy Oram, though a posting, http://radar.oreilly.com/2009/11/converting-to-electronic-healt.html

I think the very existence of the Regional Extension Centers (RECS)is but another sign that there is no workable plan for a national rollout of EHR. There is a plan, a word I use reluctantly—there may be several. Several things surrounding the rollout exist that reinforce the idea that the plan is not operational—Meaningful Use, Certification, RECs—and these things exist as a series of band-aids in the hope they will enable the plan. These band-aids have been cobbled together over time and by different parties.
There is no EHR Czar.

There is no roll out czar. I defy anyone to present their work plan for how this ties together and show where these add-ons are on the plan.

Back to RECs. Similar format to Healthcare Information Exchanges (HIEs). Political in their origin and format. Carte blanche in terms of how they are built, what they will deliver, how they relate to HIEs and standards, and how the quality of their output will be measured. Five hundred and ninety-eight hope this helps million dollars. Has anyone sought out the credentials of those running the hope-this-works RECs? Does anyone doubt that they don’t have the experience to make these of any value? Where’s the national REC work plan? The individual work plans?

Who likes the REC idea? The payors. Regionally deployed and state authorized, the payors have more than a vested interest in helping the healthcare providers in their region with their EHR efforts.

This is another lipstick on the pig effort. By now, the pig is just about covered with lipstick. Does it make it a better pig? Of course not, it just makes it red.

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Some EHRs are better than others

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The health club offers a boot camp course—see how this ties into healthcare?  I used to make fun of it until I decided to try it.  The spandex factor is about 9.8 on the spandex/Richter scale.  Thirty-something women whose color coordinated apparel makes it worth the sweat.  (Permit me a brief segue.  Some fashionista recently discovered that it was possible to convince women that instead of wearing one shirt, that it would be more fashionable to wear multiple shirts with coordinated colors.  So, the women in the boot camp course wear an array of clothes such that their headbands match their fingernail polish.)

On most days I am the lone male in the class.  I’ve summited 50 (years, for those wondering the use of the word).  Most of the women in the class are unable to have an intelligent conversation over a latte about Viet Nam.  Trying to be gentle, I attribute that to their age rather than the fact that they were waitlisted on the most recent Mensa membership drive.  Despite their inability to go mano y mano with the former secretary of defense, Robert McNamara, they look darn good in spandex.

I try not to look like I covet their fawning, but as a seven year survivor of the White Male RCA Stent Award, I accept it with a degree of grace.  (For the male readers who wish to make light of Boot Camp, try it before you tease.)

So, there I am, I am there.  It’s my Green Eggs and Ham moment.  Prior to the class I’d run five miles, and completed 33 pull-ups without stopping.  Did I mention I like being the lone male in the class?   There’s a certain adulation that goes with the title.  Some would covet the position, but as an adult, I take it in stride.

However…today another male comes to the class.  I do not mind having another male.  I do however look unfavorably having another male in the class who looks like he trains navy SEALS in his spare time.  The class had the usual amount of male gawking, albeit at the wrong person.

What does this have to do with healthcare information technology?  Not much other than it goes to show you that there are those whose efforts may have superseded your own.  It doesn’t mean much when the item in question is pushups, it means a lot more when you’re trying to determine who did the best job spending one hundred million dollars on an electronic records system.

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EHR leadership isn’t always a democracy

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CocoaPuffs

Cerealizable.

That’s my new word. I coined it the last time my wife was traveling and I was in charge of breakfast and making sure nobody missed the bus. Cerealizable is what happens when you walk into the kitchen and are confronted with two hungry dogs, three hungry kids, hair that needs brushing, homework assignments that need to be reviewed, and lunches that have to be packed.

Breakfast orders are shouted at me across the room as though I’m their short-order cook; pancakes, French toast, sausage, and who knows what else. What does one do? I was quickly headed down the path of self destruction, too many tasks and not enough taskers. I needed a light at the end of the tunnel and so I created one. I cerealized the problem; simplified it–turned into something I could solve. Go to the pantry, pull out the cardboard cereal boxes, three bowls, three spoons, and the gallon of milk. Check off breakfast.

In case you’re wondering, Cocoa Puffs still turn the milk brown, just like they did thirty years ago. Lunch orders began to be shouted across the bowls of cereal. Ham and cheese, PB&J, tuna–extra mayo, no celery. Once again small beads of perspiration formed quickly on my brow. For a moment I considered calling the school and telling them that all three were sick. That would solve the lunch problem, but it would also mean that the three of them would be home all day–my own private hostage situation. What to do? My coffee remained out of reach, still untouched. That explained the pending headache. Back to lunch. Cerealize it. “Everyone is buying lunch today,” I announced above the roar.

A half hour later, the din had subsided. I made a fresh cup of coffee and collected my thoughts. What had I learned from the exercise? Three things. One, some situations require leadership. Two, three children and one grownup is not time to establish a democracy. There is no Bill of Rights. To quote Mel Brooks, “It’s good to be the king.” Three, break the problem down into bite-sized pieces, don’t try to swallow the elephant whole.

That same approach works just as well with EHR grownups; clinical grownups and IT grownups. Improving the interaction takes leadership. Large, institution-changing projects involve pulling people out of their normal routines and relationships.  Solving problems will not involve a kumbaya moment–Program management is not a democracy. To succeed, the program champion, having created a vision, will have to break it down into bite-sized pieces.

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Who was that woman who put in our first EHR system?

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vacuum_cleaner

The first home I bought was in Denver.  Built in 1898, it lacked so many amenities that it seemed better suited as a log cabin.  There was not a single closet, perhaps because that was a time when Americans were more focused on hunting than gathering.  Compared to today’s McMansions, it was doll-house sized.

It needed work—things like electricity, water—did I mention closets?  I stripped seven costs of paint from the stairs.  Hand-built a fireplace mantel and a deck.  I arrived home to find my dog had eaten through the lathe and plaster wall of the space which served as my foyer/family room/ living room-cum-hallway.  I discovered the plaster and lathe hid a fabulous brick wall.

My choice was to patch the small hole, or remove the rest of the plaster.  Within an hour I had purchased man-tools; two mauls, chisels, and a sledge hammer.  I worked through dinner and through the night.  The only scary moment came as the steel chisel I was using connected to the wiring of two sconces which were embedded in the plaster.  On cold nights I can still feel the tingling in my left shoulder.

As the first rays of dawn carved their way through the frosted beveled glass of the front door, I wondered why I never before had noticed that the glass was frosted.  I wiped two fingers along the frost.  A fine coating of white powder came off the glass leaving two parallel tracks resembling a cross-country ski trail.  I surveyed the room only to see that the air made it look like I was standing inside of a cloud.  The fine white powder was everywhere—my Salvation Army sofa and semi-matching machine-loomed Oriental rug from the Far East (of Nebraska), a two-ton Sony television, and a component stereo system that had consumed most of much earnings.

Bachelor living can be entertaining.  One of my climbing buddies moved in with me.  The idea was I’d keep the rent low, and he’d help me by maintaining the house.  He didn’t help.  I made a list of duties; he didn’t help.  I left the vacuum in the middle of the floor, for two weeks; he didn’t help.  I made him move out, and advertised for a female roommate—an idea I now wish I’d marketed.  A girl from church came over to see the place.  I turned my back on her, only to find when I returned that she was on her hands and knees cleaning the bathroom.  I was in love.  It was like having a big sister and mother.  She even asked if it was okay if since she was doing her laundry if she did mine at the same time.  Life was oh so good.

Sometimes when one approach isn’t working it’s real easy to try something else.  And sometimes the something else gives you a solution in the form of a water-walker.  Healthcare IT and EHR aren’t ever going to be one of those sometimes.  There will be no water-walkers, no easy do-overs.  There won’t be anyone walking your hallways talking about their first wildly unsuccessful EHR implementation.  Nobody gets to wear an EHR 2.0 team hat.  Those who fail will become the detritus of holiday party conversations.  Who will be the topic of future holiday parties?  I’m just guessing, but I’m betting it will be those who failed to develop a viable Healthcare IT plan, whoever selected the EHR without developing an RFP, the persons who decided Patient Relationship Management (PRM) was a waste of money.  The good news is that with all of those people leaving your organization, it costs less to have the party.

I’d better go.  Somebody left the vacuum in the middle of the floor so I need to get cracking before my wife advertises for a female roommate.

saint

A thought about EHR companies

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Just a brief note to provide a link to my comments on the blog EHR Blog about EHR Vendors.

http://www.ehrscope.com/blog/electronic-medical-records-companies/comment-page-1/#comment-792

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A doctor writes about his EMR experience

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162_6The following is a response I received to a discussion I raised on a LinkedIn group.  It’s written by Dr. Richard Lamson and is used with his permission.  I liked that it didn’t follow some of the EMR/EHR cheerleading that seems to dominate much of what’s written.

I wish I could say it was a learning “curve”, it’s just a “slope” with no asymptote in sight for many EMR products.

Well, no, I guess that’s not right. Your cardiologist will eventually get to 30/30 or so instead of 10/50, so there is an asymptote, it’s just not what it was with paper charts. Say what you will about paper charts (they’re unreliable, slow, get lost easily — all true), they’ve been refined by several generations of physicians, using technology that was well understood 200+ years ago. The data density of pen/ink on paper is very high, (think genograms, drawings of the location of lesions, etc.), the input bandwidth very high, and it is something with which we have been familiar since preschool scribbling with crayons (of course, some physicians’ charts would be improved by scribbling lessons!).

The EMR user interfaces out there are at most 10-12 years old, The input bandwidth is not very high — at most it is dictation speed but with a higher error rate. Because of copy/paste technology, a lot of “information” in charts is copied and pasted from previous notes and does not necessarily reflect what the physican did on this visit. Also, it might not be true this time. Does every doctor look at every diabetic’s feet at every visit? I try to, but when I’m 45 minutes behind sometimes I defer it to the next visit, especially when they can’t put their own shoes back on after I take them off. I try to edit out the foot exam

Don’t get me started on the warnings that EMRs give you every time you open a new patient, write a prescription, etc. You get warning fatigue and tend to blow past them without reading them after a while, since 99+% of them are not germane (oh, this patient’s taking aspirin, maybe they’ve had a heart attack in the last 10 minutes, better not write them for a migraine medication…). These warnings are basically lawsuits waiting to happen. I can hear the attorney now: “But, Doctor, your EMR warned you that this was a bad medication to use in this case, why did you write it anyway?” “Well, you see, it had given me that warning buried in among 20 other warnings, and it was probably the only warning all day that was useful, how can I read 400 warnings a day to see which one is useful?” Cha-ching!

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