Thursday, December 18, 2008

Electronic Medical Records

One thing that Mr. Obama and I agree on regarding healthcare is that it is very important that our records go digital.  We are never going to maintain the best healthcare in the world (yes, we have the best healthcare in the world... access may be limited, but technology, skill, and delivery are still in our corner) if we can't come up with some way to maintain consistant, accurate patient histories and medication records.

From that point on, we disagree about almost everything else, including how to implement the system and who should pay for it.  But it is always nice to see areas where you agree.

Anyway, this isn't a political post, but rather a chance to spout off a few random thoughts about EMR systems.  There are a lot of systems out there, and many of them I've never used, so I'm not exactly an expert in the field, but here are a few that I have played with:

Where I am working now, we use the FirstNet program from the Cerner Millenium suite.  It is alternately called ACIS, which I think refers to the whole hospital group of programs where FirstNet is the ER part or some such drivel.  I can't speak on the nurse charting or physician order entry aspects of this software, as we only use it for the tracking board, secondary assessment capability, and lab interface.  I suppose this is not the worst software out there, but I'm not overwhelmed by it.  I appreciate how it interfaces with the rest of the hospital, and the medication reconciliation, while frustratingly slow, is actually fairly decent.  But beyond that there are literally dozens of madening aspects to it, ranging from small to homicidal-ideation-inciting points that seem like they would be such no-brainer fixes (like why do we have to have a character limit in the free-text box for each system - so when I'm talking about abdominal tenderness and last oral intake and bowel tones and which shade of green that vomit was, I run out of room and have to start cutting things out or abbreviating or eliminating spaces after periods.  Seriously, people, what's up with that?).  Another thing that really frustrates me is trying to chart pain.  When I chart on a paper chart, I can write

O - sudden
P - movement, pressure.  no palliation.
Q - throbbing, burning
R - L arm
S - 8/10
T - 3 hours, intermittent pain

This takes me about 30 seconds to do, if that.  But in Cerner, each field brings up its own individual pop-up window with checkboxes that rarely satisfy what I want to say (probably 80 percent of patients descibe their pain with throbbing or stabbing but neither of them are in the "quality" checkbox, for instance).  Why I can't type in where the pain is located and then have 1 box pop up where I can simply enter the details all at the same time is beyond me.  I know that this only takes an extra couple of minutes, but when I'm seeing anywhere from 5 to 30 patients in a shift, and stupid stuff like this takes an extra 5 or 10 minutes for each patient, it really adds up - especially when I have the doctor who writes for Dilaudid "every 15 minutes" on every patient who walks in the door (praise be for carpujects).

I have used a couple other EMRs as well, including EPIC from Epic Systems, which has a number of really great features, and no huge drawbacks that I can remember, although I do remember being frustrated from time to time at a few things.  I used it mainly in Peds and Family Practice as an LPN at a huge (40 or so doctors) comprehensive health clinic, and I really liked the way that everything was integrated into one fairly easy to use system with lots of automation and patient-friendly graphs.  Patients could send e-mail messages through the system and doctors could reply and have the whole exchange automatically entered as part of the medical record.  Messages could be sent electronically to different staff members.  Medication refills could be sent straight to the doctor for approval and then sent back electronically.  And a whole host of other really nifty features.  I also spent a good amount of time in the same organization working in the Urgent Care Center.  I found this system to be a little less intuitive for this use.  Mainly, I think, because the triage entry seemed less intelligent and the nurses' notes came out in a reader-unfriendly format.  although because physician order entry was electronic, to chart giving a medication involved checking a box for PO meds, and for IM or IV meds you just had to fill in a couple details.  Also, you could see the tracking board either as a standard list, or as a layout of the department with rooms colored based on status, which made it easy to see at a glance what was going on.

Far and away the best feature, though - and the one that I miss sorely - is the "dot phrase" that Epic allows you to use.  In medicine, we are constantly using the same or very similar phrases over and over, whether it be in charting or patient instructions or whatever.  With Epic's dot phrases, you can enter a phrase one time (or choose from a large library of pre-entered phrases) and save it with a keyword.  Then whenever you type a dot and then the keyword, such as .sleep the computer replaces that with your pre-determined phrase, such as:

patient resting quietly with eyes closed and even unlabored breathing

because everybody knows that nurses aren't qualified to determine if a patient is actually sleeping or not.  Even cooler, is that if you include three asterixes in your original phrase, then this becomes an easily-editable part of the phrase.  For instance, I could put *** after resting quietly, and then when it pops up in the charting, I can quickly go through the text and any time there is a *** it will highlight it and ask me what to replace it with, so I could put "on his back" or "on his right side" or "in the sink" and then move on.  Even cooler, is that a lot of data from the patient's medical record can be called up in a similar fashion, so if I made a phrase such as:

.name is a .age .gender who complains of .cc for *** days.  .he has allergies to .allergies and regularly takes .meds.

and saved it under the keyword .triage, then when I type that keyword, I will get something like this:

Braden is a 72 year old male who complains of nausea and vomitting for *** days.  He (this phrase calls up the gender and puts the appropriate pronoun in place) has allergies to aspirin, ibuprofen, tylenol, and tramadol and regularly takes vitamin b12.

At that point, I hit the tab key (if I remember correctly) and it highlights my free text spot (the ***) and I can type what I want.  And of course the whole thing can be edited, so if anything doesn't apply I can delete it or add what I want.

Needless to say (but I'm saying it anyway), this saves immense amounts of time, and makes it so that you can write all the lawyer friendly stuff (patient tolerate procedure well, for instance) without having to wear out your hands and take the time to write the same thing over and over again.  I could chart a very thorough summary of crutch teaching, for instance, including documenting return demonstration, height of crutches and everything else, by just typing .crutch and then editing a detail or two.  Boom, 15 seconds spent on what would otherwise take a minute.  Multiply that times every patient encounter of the day, and perhaps you can understand why I miss this feature so much.

Okay, enough free advertisement for EPIC.  Are you still reading?  Good.

The other system that I have used is Ibex PulseCheck from Picis.  I remember being impressed with it because it was so simple and straightforward.  That said, there are very few specifics that I can remember to either praise or denegrate the program.  One thing that I do remember liking, however, was that the background color of the screen could be modified based on conditions, so when there was a blue screen, that meant that things were going well and you could bring your own patients back, but when there was a red screen it meant that we were getting busy or had a lot of ambulances on the way, so only the charge nurse could assign patients to rooms.  At the time I used this, I was an ER Tech, so most of my documentation consisted of charting blood draws, splints, EKGs and patient transports, so I really can't speak too much for how easy it is to do nursing assessments or med documentation on this system, though it seems that most of the nurses seemed to like it once they got used to it.

Another hospital I did clinical rotations at in nursing school used a DOS based system from the 1600s.  I would rather engrave the medical record in stone tablets than go back to that hospital.

Anyway, each of these systems has really nice features and each has features that just make me scratch my head and wonder if anybody is really thinking this through.  This gave me the crazy idea that I could come up with a good EMR, and since my brother is a computer programmer (who brings in almost 2.5 times my salary), maybe we could get something started and strike it rich.  So I've been jotting down notes every time I think of something that I want in my EMR, and although I know deep down that it is an impossible dream, I keep getting excited at the idea of solving all of the worlds medical records woes.

So I told him about the idea the other day and he said that not only is it a bigger project than I realize, but it involves a school of programming that he is not interested in, and besides, a clause in his contract states that anything he works on while employed by Software Giant, Inc, becomes their property.

Oh well.  Nice dream anyway.

So for all you intrepid souls who have followed me this far, what EMR do you use and what do you think of it?


GrumpyRN said...

"We are never going to maintain the best healthcare in the world (yes, we have the best healthcare in the world... access may be limited, but technology, skill, and delivery are still in our corner)"
Sorry Braden, but you are not even close, last figures made US 37th in world (WHO 2000). Since then from what I am reading from bloggers and picking up on the media and internet that position can only have gone down. I would agree with you about your technology but I would suggest that your skills are the same as everyone elses and from the UK your access and delivery can sometimes look third world. I am not making a direct comparison between US and UK because I am sure that any isolated story can support both our point of view. This is not meant as anti American but purely a simple comment from someone who has no personal experience of the American health system.

Anonymous said...

We are currently using FirstNet in our ED. We will Go Live on EPIC next month. Should be interesting.

Braden said...

Grumpy - I don't want to get in a fight about healthcare delivery, but I see what you are saying.

Dr. J - What is your assessment of FirstNet? Do you find my opinion to be fairly accurate or do you have a different view of the program?

Anonymous said...

Well, we mostly use FirsNet for tracking and order entry. Charting is still on the old paper T-sheet. When we go live with EPIC next month,EVERYTHING will be electronic. It will be good for the hospital system as a whole, but for the ER it will be terrible. EPIC charting and order entry was NOT designed for Emergency Medicine, but we are forced to use it for the "greater good" of the hospital. Hmmmmm, starting to sound an awful lot like an Obamanation ;)

Anonymous said...

we use the Mckesson system. We started EMR throughout our 4 hospital system about 6 months ago. I think that EMR is great if you have the right program. McKesson however, has not been working too well for anybody. The program crashes at least once a week, even after continuous attempts from IT to build new networks, and who knows what else. The program just doesn't work well throughout the hospital for all areas. Wouldn't recommend it

Lynn Dykstra said...

I am a clinical instructor, and I would love there to be an instructor mode where all the student's notations would pop up so we wouldn't have to mine the record at the end of each shift with each of them trying to remember every section they made an entry. I limit them to several screens so I can sign off without too much searching, but it could be so much easier. I've talked to EPIC people about this, but nursing instructors needs are not their focus for inovation!

Anonymous said...

We have cerner locally and I HATE it. Mainly the multiple logins, actually, but that makes a vile first impression. I've also used meditech, and frankly, that's worse.

Hopefully, they'll evolve.

In the office, we use Practice Solutions and it's brilliant and keeps getting better.

Also, you're wrong wrong wrong about the US having the best healthcare. Some excellent technologies, for sure, but in terms of cutting edge research, you guys aren't even competing with South Africa for heaven's sakes!