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Can We Talk? Challenges of SaaS Type EMR User Interfaces

Forget about EMR interoperability between doctors’ offices and hospitals for a moment.

One of the recent developments in the ever-expanding SaaS (software as a service) world of electronic medical records must be the challenge of making all the individual software components talk together correctly.

There is (1) the EMR itself, (2) the programming platform/language, and the (3) internet browser.  Forgive the novice in me if I don’t get all my nomenclature correct.  I’m just a doctor.  If one component gets upgraded (and they always do), then the house of cards can come tumbling down in one fell swoop, at least temporarily.  We’ve experienced this recently at our office with our own EMR system and so I have a few thoughts on the matter.

In our office, first it was Firefox stopped working with the EMR.  Then we all switched over to Internet Explorer, which seemed to work for a time, but then that stopped working well and frequently froze up.  Chrome is working for now, but it seems to be only a ticking timebomb before this no longer works.

To make matters more complicated, different browsers have different ways of displaying information bars at the top, sides and bottom of the EMR window, and so some bars can get in the way of viewing different parts of the screen depending on which browser is used.  There are ways around this (conveniently called “workarounds”), but yet again, not so simple or straightforward and thus suboptimal.  I have to admit that it sort of feels like jiggling the handle on an old toilet to get it to stop running.  In other words, yes, you can do it, but, no, it doesn’t feel like it should work that way ideally.

We’ve been given the explanation that Adobe Flash is having problems interacting with the EMR system, or vice versa, since both the EMR and Flash have gone through successive, iterative upgrades to improve and add functionality to both services.  I can totally buy this explanation.  However, at what point will it just get too difficult to keep everything going?  Is it impossible?  Probably not.  But it’s a heck of a pain watching the EMR go through roadblocks as we forge into the future together, as vendor and provider.

This will undoubtedly affect any EMR system that is dependent upon other, third-party software.  It is a common situation that will change over time, and I’m almost certain that this is going to be a challenge, all around, for any EMR system on the market today.  As such is the case, I look forward to the day when it can be solved permanently by adopting a new standard for all platforms.

August 20, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Does Meaningful Use Destroy Doctors’ Skills?

About two weeks ago, I saw a patient who was referred for a new diagnosis of hypocalcemia (low blood calcium levels).  I ran a few additional appropriate lab tests and will be seeing him back this week or next.  This weekend, however, I had some spare time to read back through the sections of two medical textbooks dealing with a more detailed discussion of this issue.

How apropos, I thought, when reading a recent post on the Health Care Blog, titled The Destructiveness of Measures.  This post says such a powerful amount in such a short blog span, that I needed to highlight and share it.  It succinctly describes what the government is currently trying to do to a highly trained labor force who’s best asset is their ability to think about patients with complex medical problems.  Every minute spent filling out online forms to report meaningful use data to the government could be better spent in reviewing and updating their medical knowledge set.  Both tasks focus on patient’s and their medical problems, yet one is a much higher yield for patient care and physicians’ sharpness in providing higher quality care than the other, which could be completed by a person with a high school education.

Let’s not dumb down our physician’s knowledge levels by asking them to complete such inane tasks as generating Meaningful Use data sets.  Are the physicians the right personnel for such a clerical job?  Absolutely not.  Airline pilots can’t maintain their flying skills by running the beverage cart.  Doctors are no different.

July 23, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

How an EMR gets in the way of doctor-patient relationships

For all of the glorification of EMRs and EHRs and pushing into the new age of digital healthcare, I thought I would throw in my 2 cents from the dark side of electronic health record keeping.  To be honest, there are a few things that could be greatly improved.

Now, before I get a whole bunch of unsolicited email from EMR vendors out there waiting to pounce on me with sales pitches of how theirs is better and I should give it a try, I should say that I’m very happy with my current EMR system and not looking to switch.

That notwithstanding, there are a few simple concepts that no EMR system to my knowledge has gotten right yet.  It’s even possible that it may be hard to ever get right, and a lot of it has to do with mouse clicks and typing.

During my average day, I feel the need to maintain at least some eye contact with my patients, mostly because I’m a bit uncomfortable with the amount of time I have to spend looking at my computer.  I’m a bit of a slave to the computer system in that sense.  I know I could do all of the documentation after the patient is gone, but I’m afraid of missing something in the documentation.  You could say I could just scratch notes on paper to avoid missing anything, but this is not in keeping with the lofty goal of being paperless, now is it?  Maybe the lofty point is just to eliminate paper charts.  Still, scraps of paper doesn’t really sound modern or safe now, does it?

I also feel a bit uncomfortable giving up my nights and weekends just to “look good” in front of my patients.  A burned out doctor who has no life outside the office to spend with family and friends, and who ultimately quits the profession because of such, is not an ethical thing to expect of physicians, is it?

And so, for now, I do my best to incorporate a bit of eye contact, but still spend time typing away with the patient across my desk watching me and telling me about their issues.

The EMR still requires a lot of additional tasks outside of documentation: electronic prescribing, reviewing messages from staff and performing additional tasks as necessitated by these messages.  And all of these tasks take a considerable amount of time.  Up until now, they have required human intervention to complete, but what about the future?

One of my recent hobbies is reading history texts.  Interestingly, one of the stimuli that encouraged the Europeans to seek an alternative passage to the Far East was the excessive trading fees imposed by transmitting goods through Muslim and African nations.  An alternative route that would allow the elimination of hefty fees and allow them to run their import-export businesses cheaper and more efficiently was the dream.

If we can automate all of the EMR tasks more effectively using a Siri-like voice-activated platform, then medical providers may be able to achieve all of their work during normal business operating hours, face the patients when they speak, and have a better quality of work and home life than their predecessors.  I’d love to be able to tell my computer to send in a scrip refill for thyroid hormone and it would be done, without the need for any other steps or human involvement, but that remains a far off mirage at this point.

The more an EMR can do for me, the more time I can spend in humanistic and meaningful contact with patients.  I dream of actually living the dream but for now live in the reality of a less than perfect world.

July 16, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Guest Post: Do EMRs Cause a Mirage of Health?

This is a guest post by Ken Harrington, Practice Manager at the Washington Endocrine Clinic.

The smart phone (blackberry, android, iphone) is an icon of the postmodern age.  In my fingertips, I hold the power of the internet.  I can look up my e-mail messages in real time, search anything in the world on the web, and be socially connected to a world-wide community of people – all in the palm of my hand.  This concept is slowly being applied to medical records.

Many of the new EMR systems that are beginning to infiltrate into the physician’s office now allow patients access (even if partial for now) to their own medical record.  With a few clicks of the computer mouse, a patient can now access his or her labs, radiology, and pathology reports.  Even better, the EMR that we use at the doctor’s office in which I work will soon be available on the iPhone and iPad.  This will enable any of the patients in our office to login anywhere and have instant access to their medical chart.  No longer does a patient have to guess at what she thought the doctor said or didn’t say about her results – the patient can now have access to the official record herself.

This gives a patient a lot of new power over his own healthcare that he did not previously hold.  For example, now the patient can research online about cholesterol if his test results show he had an elevated level. Granted he still cannot write his own prescription for a medication, but he can educate himself and use that knowledge when he speaks to his doctor about the test results.  This is a game changer of sorts which will add the physician’s office to the growing list of other institutions that have become transparent in the postmodern age.

This is all good for the consumer/patient – right?  On many levels, it is.  Patient empowerment in the realm of healthcare is what doctors have been complaining about for years.  Theoretically, this should lead to the patient having greater control over the choices she can make regarding her healthcare.

To boost this empowerment, certain companies are taking all of this patient data and showing what the future could look like.  The particular EMR that we use is partnering with a start-up company called 100Plus.  100Plus is taking the data and filtering it through a computer algorithm to project what someone’s future health would look like if he did not make the recommended choices to improve his health.  A future projection might mean death 10 years earlier if he had not made the choice to start exercising and eating right when the test results began to show a problem.  The entrepreneurs behind 100Plus know they have a market-winning idea because, in the postmodern world, people want to take control of their reality, including their health, as much as possible. This is just one more way to gain a little bit more control.

But what really do you gain by having all of this control and power?  A recent news article described a doctor in California who offered himself up as a test case for a new personal human genome sequencing test.  This test would look at whether a person’s DNA sequence could foretell that the person would be more predisposed to certain diseases over others.  This particular doctor’s test result showed he had a strong predisposition in his genes for developing diabetes, despite that fact that he was in good shape and ate health-consciously. However, six months after the test results were reviewed, the doctor was diagnosed with diabetes.

This makes me wonder whether it’s possible to have ultimate control over one’s health. Will access to a patient’s medical chart cause them to make better choices – or any choice – to improve their health? One would think it would at least give them a leg-up on the limited choices their recent ancestors had and make life-changing decisions possible sooner rather than later. But sometimes empowerment leads people to think that they have ultimate control and can make all the right choices. I’m not convinced that this is the case. If it is built into my genes that I am gong to die of a disease that I cannot do much about, doesn’t this level of transparency simply cause me to worry about something I have no control over? I guess you could say, “Well, we will all die of something, and if we know what that something might be, then we might try to limit its damage with better choices now.” But, unless someone can actually change the direction of my genes, I might actually be quite limited still in what I know.

The same may hold true for open EMRs. If the patient is focused enough to make choices with the knowledge they now have on a 24/7 basis, will it cause their health to be any better? Maybe. But could patients’ thoughts that they have a growing control over their own healthcare (via knowledge of their medical records) also potentially lead to developing a culture of false security? In other words, will such thinking only lead to a mirage of health? For me, I think it might.

* Dr. West’s note: This reminds me of a book titled “Mirage of Health” by Rene Dubos, the famous microbiologist who wrote that mankind develops a false sense of security with the acquisition of technological advances over his environment.

May 29, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Readers speak about computing in front of patients

A couple of readers did me the honor of commenting on other boards about my last post on whether or not to compute in front of patients, and so I thought I would add a new post showing my appreciation to them for their insightful comments and adding a few of my own thoughts.

Patrick Howard wrote:
“It’s all about educating the patient. If the patient understood what you can do with the technology (flowsheets, care coordination, etc.) then they would insist on the use of EHR’s.”

Many of my patients are so glad that everything is documented clearly in a modern electronic record and have told me so. The feeling I get from them is that they are relieved to be in a practice that keeps up to date with technology, and I do think they equate this with better care (whether this is true or only perceived as true).

Patrick also wrote, “…you can also deflect some of this just by putting a sign in the waiting room, explaining why we are now using electronic charts and what it means to your care. 
Again, it’s about educating!!!”

This is a good thought for a proactive action plan. In my post, I had commented on how patient complaints about the EHR were very rare. If this starts to happen more frequently, then I may do just as Patrick suggested and make an alert sign.

Dr. Tim Thurston wrote:

“I read and enjoy your blog regularly. I am a pediatrician and we have been on EHR for over 5 years. I do all my documentation in the room face to face with the patient/parent including sending the eRx. I basically talk to them what I am typing which reinforces my findings and recommendations. I can then reinforce what I have said by handing them a personal plan that I typed while in the room. During the actual physical exam the laptop is out of the way which offers plenty of time to discuss without the barrier of the computer screen.”

Why thank you Dr. Thurston! I appreciate all of my readers, especially those who care enough to give me the gift of their comments.

As far as documenting while speaking, I have done this a fair amount as well, but not for each encounter. When I do it, I often speak slowly as I am typing so that the patient hears my thoughts again for reinforcement. I even remember a patient commenting on how he enjoyed knowing exactly what I was writing in his chart. Often, patients have a conversation with their doctor and the doctor ends up writing something that the patient later disputes as inaccurate after gaining access their chart notes. Once it’s in the notes and they’re signed, there’s no erasing, only addending. I find that getting the all right the first time is actually cleaner and less of a hassle later.

“It is here to stay and we as docs just need to find ways such as you often mention in your column to continue to make it more friendly to the patient.”

Yes, I love my EMR system and it will stay with me.  I  think that in the future, though, the technology will become more efficient and creative and allow us as physicians to get back to spending more time thinking about and talking with our patients.

May 7, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

To compute or not to compute in front of patients, that is the EMR question.

Rarely do I become accosted by a patient with a preconceived notion that doctors should not be using computers, at least not in front of patients.  However, I’ve had at least two instances in my recall in which patients told me they were not being paid enough attention.  I find that these patients are usually what most professionals would refer to as “special”  and that this usually manifests itself in some aspect of the visit or later.

About two years ago, I recall a young, approximately 30 year old gentleman who never said anything out of the ordinary during our initial visit but later on the phone told me that I had rudely “shushed” him during our visit and that I had also said to him a whole cadre of other bizarre things that I don’t recall ever saying to any patient.  When I spoke to him on the phone about why he had not completed any of the recommended testing, my blood ran a bit cold and I seriously wondered if he was an undiagnosed schizophrenic person who had heard bizarre voices and supposed that those were mine.  To this day, I remain in question of it.

A few weeks go, a 60 year-old woman whom I saw suddenly lit into me, mid interview, when I was typing in her responses while talking with her across my desk.  My face was admittedly not on hers at that exact moment but at an angle of about 30 degrees off.  ”You know I have to say this is the second time this week that I have been to see a doctor where the doctor’s face is on the computer and not mine.  Frankly, I find it very disconcerting!”  Of course, I apologized and immediately turned to her and said, “It’s okay, how about we just talk like this?”  I finished the interview professionally and felt that she was safe to follow up with her primary doctor since only an explanation of her mild lab abnormalities was necessary.  During the rest of our visit, she told me that she was not fond of doctors at all lately since they weren’t doing her any good, just reassuring her that her conditions could be monitored periodically without treatment.  I seriously looked at her with raised eyebrows and put it back on her a bit, asking, “Do you really want me to tell you something is seriously wrong with you?”  She finally broke a grin and chuckled (as I briefly thought about kicking her out of my fourth floor window).  Normally, I would have offered to follow her for an annual visit, but under the circumstances, I felt it would have been more pleasant for both of us if I didn’t see her again.  As she checked out and said she hoped I wouldn’t hold her comments against her, I smiled and said that this was becoming the norm and she should not be surprised if all of her visits eventually came to this.

Luckily, these examples are very rare.  One patient recently wrote about her negative experience with EHR charting at the time of the visit in one of my favorite magazines, Physicians Practice.  I would hope that patients understand that computers are here to stay, and I’m not going to hold off on documenting all of their related medical notes until after they’ve left.  But I do try to at least face patients during our visits.  My computer is in my office, where I conduct interviews, and not in the exam room, where I am only examining patients.  I already spend far too much time calling people back, sending in scrips and filling out paperwork outside of my normal office hours.  To add extra time in this area of routine documentation during nights and weekends would not be time well spent.

April 23, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Scanning 101 for electronic doctors’ offices

Know what I did last summer?   Killed some guy on the side of the road.  That’s what I might have said if I were Jennifer Love Hewitt.  Forgive the bad humor.

Actually, I invested in one of the single most valuable pieces of equipment in my office, a high speed scanner.  For the price tag of around $1,500.00, I was able to sidestep hiring another $35,000/year staff member to sit around and scan documents and old medical records all day long on our slow, old scanner.

Our trusty older scanner is part of an HP “all-in-one” printer combo that still sits in our office, performing its job of faithfully printing all of our documents, and scanning a very few documents lately.  The biggest problems with using this older multipurpose machine as a scanner included: (1) inability to print and scan at the same time, and (2) slowness at 5 pages per minute (let me just say, “OH MY GOD! THE PAIN!”).

Trust me guys, get yourselves some of the high speed stuff.  It’s such a joy to use the right tool for the right job.

March 23, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Intake paperwork reduction in the doctor’s office using electronic records.

You might think there would not be much paperwork, if any, involved in a modern doctor’s office using electronic health records. However, while we strive for a truly paperless office, the real situation often amounts to being about 95% paperless.

Part of the problem is that a most offices are still on paper and so the patient ends up carting in thick piles that need to be scanned and then, in many cases, shredded.  What a waste of — albeit someone else’s — paper and ink!  One of the joys of my life is getting all of the patient’s records faxed over, which of course arrives digitally in our fax email account, ready to download, rename, and upload to the patient’s file.  All without a drop of ink touching a single sheet of paper.

In the old days before electronic records, this process would have been impossible, and the end result would be walls full of thick patient charts.  I once knew an unfortunate secretary who had her arm broken when a heavy wall rack, full of charts, fell over on her.

In my office, we are also able to accept PDF registration forms that can be either faxed or emailed.   Tech-savvy patients, which are becoming the norm these days, are able to easily and quickly shoot us their registration form before the day of their appointment.  These are uploaded to their electronic charts as soon as they come through the electronic pipeline, which really saves time during check-in on their appointment date.

If the old medical records and registration forms have arrived ahead of time, then my staff’s job is very easy.  All they need to do is make a copy of the patient’s insurance card and photo ID and whisk the patient back into an exam room to begin their visit.  That whole process can take less than 5 minutes.  Patients are seen on time because there is little left to distract a staff member from during this honed, highly efficient process.

March 12, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Electronic Medical Records Cleaned My Desk

For the past few weeks, several patients have commented to me how remarkably clean my desk is.  Usually the flavor of the comments range from amazed to inspired, but I think some people have been downright flabbergasted and just don’t know what to think of it.  For all of statements, I think in general there was an agreement that “Wait a minute, something is definitely different in here.”   They seem to be used to being in offices piled high with papers, charts, and other disheveled things of the like.

Even though I began my private practice in 2009 based on the use of electronic medical records, for a long time I had a lot of things that I just didn’t put things away after I took them out to read.  Textbooks look up clinical guidelines and recommendations on how to address complex patient issues, recommendations for new products left behind by sales reps, mail that was opened but not filed appropriately, etc.

Then, one by one, day by day, my desk got a bit less busy.  Less papers needed to be printed out, more could be done, signed, and faxed back without ever touching ink to paper.  In short, efficiency came to town in the form of digital records and faxes.  My inner child that loves the look of clean showroom furniture took over and I just got rid of the clutter, bit by bit, until nothing remained except the computer.

I largely credit the digital age for this.  During the workday these days, a few pieces of paper come across my path, but in the end none seem to survive anymore.  The simplicity of a clean desk in a doctor’s office illustrates a beautiful symbiosis between the practice of age-old medicine and the modernization of the electronic work force.

February 14, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Good Templating in EMRs and EHRs

Recently, I explored the question of what goes into a “good” template for EMR and EHR software programs. My post Good Templating in EMRs and EHRs can be found over at EHR Outlook.  Hope you enjoy it, and always remember that your EMR/EHR documentation style should be as you like it.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine and opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.  He blogs at HappyEMRDoctor.com and EHROutlook.com.

October 31, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.