EMR Wannabe - Part 2

TRAINING ON YOUR PARADE

Well, here comes one short thread given such an obvious commandment: thou shalt not spend more than 1 hour in EMR training: that’s 60 minutes, 3600 seconds or one episode of Criminal Minds commercial breaks included. That’s right: one episode, not the whole season.

I remember once spending 45 hours training on an EMR system - which we ended up not using since it was about as daunting as singing Gangnam Style in a Korean karaoke bar full of mocking teenagers.

45 hours in a training room? That's 45 hours taken away from my patients. Multiply that by 150$ an hour: that’s $6,750 of my time that will never get billed by the hospital. Not to mention the vendor’s training invoice, which came down to roughly $15,000 per physician. Total: $21,750 down the drain. In a new age where hospitals are trying to go LEAN, this sounds like massive waste begging to be recycled. Multiply this by 5 different systems for 5 different departments and you suddenly enter a new dimension where “broke” and “burnout” share the same dictionary entry.

I recently spoke to a couple of physicians running a GP in the UK. They couldn’t recall exactly how long they'd spent on the torture chair but what they remember perfectly is the training bill: £70,000 divided by 2 users; that's £35,000 a pop.

Morals of the story: waste starts where training fails to end. Which pushes our little commandment to get more specific:

"If over an hour thou shalt labor at more than $1,000 per user, thou shalt go back to the pit while vendors rework their price list. For thou shalt not bow down and pay for blurry guesstimates meant to compensate for shortcomings that are not thine to begin with. Thou art a care provider, not a sacrificial cash cow with a golden umbrella.”   

 

Good Vibrations Demo

Some say beauty is in the eye of the beholder. Right now, it’s in the eye of the doctors gathered in front of my brand new iPad. Many thanks to Dr. Voice for bringing this article to our attention. If this is the future of Medical Records, we are so in.

These more-than-decent graphic interfaces are nothing short of tropical music to our winter ear muffs. We love the color schemes, symbols and other visual cues; now that’s what we call visual intelligence.

Conclusion? If this was a lady, we would all be fighting for her number right now. Let's just hope my wife won't stumble upon this thread.

 

EMR Wannabe - Part 1

CLINICAL DOCUMENTATION

NOW I'LL TELL YOU WHAT I WANT, WHAT I REALLY REALLY WANT

Enough bitching like a Spice Girl, it's time to structure my wish list and share it with you, dear vendors. Let's start with my favorite topic if you don't mind: Clinical Documentation and Data Input.

So here's my story from A to Z...if you wanna get with me, you gotta listen carefully.

When it comes to clinical documentation, physicians enter what I call the “choose your poison” zone. We are pretty much forced into the input method the system can handle, unless it’s the one our budget can afford. Sometimes it’s the good old dictation-transcription route, sometimes we get front-end voice rec, but most of the time we get such a piece of crap we end up sticking to paper like a piece of old bubble gum.

Thing is: even if we were offered THE one revolutionary method against another, it would NOT square the crazy-making circle. Why? Because I don’t see doctors using one or two input methods. I see them using a whole bunch of them, depending on who they are, where they are and what they are doing. So if you asked me to sum up clinical documentation 101 in a sentence, I would say it’s a generous mix and match of various input methods supported by hardware flexibility at the point of care. Period.

By supporting all (and I mean ALL) input methods, you factor in the most important ingredient out there: the human one. It’s taking into account the fact that physicians have various comfort levels towards technology, the fact that physicians and nurses work differently, the fact that expectations and workflows vary from a department to another, you name it.

So if you wanna be my EMR, you gotta get with my friends. And since you can’t teach physicians new tricks because they don’t have time – I know I’m repeating myself here but your neurotransmitters need to get the point eventually: WE DON’T HAVE TIME), you have no choice but to get it right. We’re paying you, vendors, to take it on your own time to understand the way we work and simplify clinical documentation to the point where, yeah, finally, we’re able to spend more time with patients. That’s our Holy Grail. You can slam your body down and wind it all around for as long as you like, if you don’t get that right, you’re zigazig out.

Then for those who get it right, they still have to price it right. But I’ll keep that scary spice for a later post. For now, let’s concentrate on the clinical documentation cocktail I’d like you to serve on a silver platter – on the rocks. Please make it last forever and our friendship shall never end.

GIRLS JUST WANNA HAVE FORMS

If you wanna hear my nurse friends sing “zigazig ha” while filling in their Braden and Glasgow scales, give them what they crave for: smart electronic forms that are fun to fill in. Yes, I said it: “FUN”. Give them drop downs, radio buttons, check boxes, sliders, colorful YES-NO buttons and thou shalt be rewarded. But don’t forget to upload their input in the patient file. Sounds obvious, but hey, we never know…

Even for physicians in certain specialties, forms remain a powerful tool to collect structured information in a familiar way. It’s context-sensitive, it’s simple and mandatory fields force everyone to fully document patient care. And while the sounds we hear while filling in one of these is “Check, check, check”, what the system hears is the corresponding medical music, which then shows up in the final report. That’s synoptic reporting at its very best. But it won’t work without a profound, authentic desire to structure data and one heck of a cool, intuitive user interface (think Apple and you’ll stop serving us oranges).

WE WANT (REAL) MOBILE DICTATION

Of course we do. Thou shalt therefore support computers, smartphones and stupid phones all at once. OS include, of course, Windows Mobile, BlackBerry and Apple. Connections span Wi-Fi, VoIP, WiMax, 4G, LTE and email. Ah, I almost forgot: thou shalt also support offline mode while ensuring patient data never sits on the device itself. Last but not least, we want to be able to start a dictation from one device - let’s say a smartphone - and finish it on a computer since we’ve been interrupted 5 times in the course of the dictation and we ended up in 5 different places. Yep, that’s how we work.

WE WANT FLEXIBLE SPEECH RECOGNITION

Don’t force us to correct our own reports if we don’t have time for that. The question is not whether back-end is better or cheaper than front-end, the question is: why aren’t we systematically offered both options at any point in time? Speech recognition without flexibility makes no sense whatsoever, given the crazy environment we evolve in, not to mention the needs and workflows inherent to each department. While shadow gazers will love wrapping up their own reports at laser speed, my road-runner friends from the pit will want to dictate notes on the fly and have them routed to secretaries in the background for a later sign off. On my end, I’ll feel like front-end on Mondays and back-end on Fridays. So what? It’s gonna cost the equivalent of a Posh Spice wardrobe? Too bad. I won’t change my mood (I’m a doctor for Christ’s sake). So don't go wasting my precious time, get your price list together and we will be just fine.

WE WANT FUZZY GRAMMAR AND OTHER COOL GADGETS

Fuzzy grammar extracts structured data from sections of unstructured text while using pattern matching or more general grammar-based techniques. Example: I say “60 over 79” and the system goes straight to the diastolic pressure field and fills it in. Cool hey?

Even cooler: feedback on errors and low confidence results, ability to navigate the entire system with voice commands, ability to toggle languages and specialty-contexts anytime. Food for code…

WE WANT MAGIC WANDS

What I mean by that is canned text that can be inserted into a report via voice control or a dedicated panel. For instance, I dictate a single word and the system expands that into a term, line, paragraph or even completed report.  Demographics or data from the patient dashboard can even automatically be filled in this way. That’s another way to eliminate repetitive data entry and related (stupid) errors.

WE WANT ELECTRONIC HANDWRITING RECOGNITION

On tablets and touchscreens. If handwritten notes still account for a good chunk of documentation methods, it’s not only because EMRs drive physicians nuts. It’s because it makes sense sometimes. So we want an engine that translates handwriting into structured data. Come on, don’t be hasty, give it a try.

WE WANNA CHART ON IMAGES

Because that’s perfect for describing a wound, for instance. In this picture-perfect world, we want to pull up those images directly from the system and do our little marks and scribbling on them. But if I, Doctor Picasso, feel in the mood to draw it all by myself, I should be able to upload my own artwork as well.

WE WANT “COMPOUND DOCUMENTATION”

What I mean by that is that a report is, in fact, a collection of sections (i.e.: allergies, past medical history, physical exam, medication, etc.). Physicians can enter information into each section of the document separately. Why is this important? Because when data is structured in sections as opposed to blurbs of text, it becomes searchable...and reusable. Sections, whether created by me, Fred the Bonehead or Cath the Jockey are considered can be inherited from one report to another, saving us time since we don’t have to dictate the same thing twice.

The system assembles each section in the background to form a completed report based on pre-designed layout, formatting, demographics logo, headers and footers as initially and centrally set up by the Medical Records Department in the system.

WE WANT AUTOMATED DISCHARGE REMINDERS

Once a patient is discharged, you gotta, you gotta, you gotta…create a pending report that reminds the physician or the department that a discharge summary must be created and released.  Easy as 1-2-free.

That’s it for today…apologies for the long post. Please feel free to comment with suggestions and ideas from your own wish list! Next week: I’ll tell you what I want, what I really really want when it comes to Training. And I’ll try to keep it zigazig shorter this time.

Cheers from the pit,

Doc Nado

It's itchy. It's scratchy. It's reality.

ITCHY URL:

Copy and paste in patient files: EMR pandemic figures unveiled.

SCRATCHY COMMENT:

Bah...as long as they don't cut...

It's itchy. It's scratchy. It's reality.

ITCHY URL:

Despite Huge Investments in Electronic Health Records, Cost Savings Still Elusive

SCRATCHY COMMENT:

Really?

Good Question...

Fresh thoughts, frozen ends and warm wishes. What’s there not to love about the New Year?

 

So let me kick start this one on my favorite topic: clinical documentation. Complex topic, yes, but simplifying complexity is our brain’s favorite activity, right? Makes us feel intelligent and stuff. And now that computers got almost as intelligent as their walking fathers, it seems we’re all geared to solve the biggest mystery ever besides “where the hell is Atlantis?”: why are medical errors still the third-leading cause of death in the country, behind heart disease and cancer, and showing no sign of decreasing? Good question.

 

Study* says: “the equivalent of 390 jumbo jets full of people are dying each year due to likely preventable, in-hospital medical errors.” How much of this stems from poor clinical documentation, we don’t know. And trust me, we don’t want to know. And the fact that we don’t want to know means that we know. You know? Oh, shut up, Doctor-Nado-knows-better.

 

OK, I’ll pack it in. Next year. In the meantime, there’s another figure I’d like us to sharpen our teeth upon: transcription costs. $7 billion a year, and showing no sign of decreasing either – despite the flourishing rise of technologies that all claim in unison they lower those very costs. Isn’t there something wrong with the equation? At least that's what I would think after reading Economics for Dummies.

 

$7 billion a year. That’s 10$ a report. No, that’s not expensive. That’s bang-your-head-against-the-hospital-wall expensive. Let’s compare this to an industry with similar reporting needs: Legal. I don’t think any right-minded attorney out there would smile at a 10$ cut to his billable hours, would he? Good question.

But what this figure really tells us is that dictation and back-end voice recognition are still the main routes from consult to report because it’s the fastest one, from a physician’s perspective - a detail EMR vendors tend to disregard. So anyone claiming that they have a better solution that dictation and backend voice rec is a Mickey Mouth - or has been so far. Time remains physicians’ most precious tool and I'm afraid it might be so for a while. Until you vendors figure this out, we’ll stick to our speech mikes.

 

So here we are, surrounded by miracle software that have nothing to do with the fact that Joe Blow died because Nurse T couldn’t find the right dosage in time among the medical record mess. And if it costs another 10 bucks to issue the report describing the poor guy’s agony, it’s nobody's fault either. Welcome to Twenty Thirteen.

 

OK. All this is fine but cynicism won’t help answer the one and only meaningful question at stake here: why? Why, despite all the computers around, are we failing to issue quality, reliable and timely clinical documentation at reasonable costs? Good question.

 

Because we’re trapped in marketing Lalaland, people. And we’re guilty as charged. We were told “that simply installing EHRs will transform healthcare, improve quality, save money, solve the national debt crisis, and bring about world peace. We are shocked to discover it hasn’t happened – and it won’t in the current healthcare system.” I’m quoting an MD called Ashish Jha here, and guess what?

 

He’s damn right. The more we let vendors tell us what time it is, the fewer questions we ask about the weather. And whatever is left to ask will be the wrong questions, which “always produce an irrelevant answer, no matter how well-crafted that answer might be” - still according to Jha, who goes on to conclude: “unfortunately the debate on health information technology seems to be increasingly focused on the wrong question.”

 

And where are the wrong questions typically asked? In the right documents: RFPs. Hence the damage.

 

So here’s my good resolution for 2013: craft one hell of a killer RFP that raises the middle finger to “political” pressures, asks the right questions in readable English and has built-in radars for bullshit answers - already working on it. Those who feel like stepping in this little creative train will see a bunch of threads inviting them onboard over the next few weeks.

Happy New Year, dear vendors. In 2013, only the fittest shall survive. I've read it somewhere. Ah, yeah, it was in Evolution for Dummies.

* Source: HealthGrades
 

Bullshit Bingo!

Vendor meetings will never be the same again

Do you keep falling asleep during vendor presentations? Not to worry. Here comes Bullshit Bingo - EMR Edition. Right in time for the Holiday Season.

1.   Before the meeting starts, print one copy of this game card for each player.

2.   Check off a block every time you hear the Sales Rep say this word during the meeting. The first to get a full line horizontally, vertically, or diagonally stands up and shouts "BULLSHIT!!!" Great way to tell the guy “cut the crap, show me the code” ;-)

Note: you can also play BB during wine-and-dines as a drinking game; for every block you mark off, take a sip, and finish your drink each time you get five blocks in a row. Enjoy!

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