“An error doesn’t become a mistake until you refuse to correct it.” – Orlando A. Battista
So much happens each and every week, and it’s hard to keep up sometimes. Here are some of the tabs that are open in my browser this morning along with some random thoughts….
The mug below was sitting next to my laptop filled with chocolate covered espresso beans last Saturday morning, Valentine’s Day. A gift from my lovely wife. Apparently she’s aware of my addiction. It made me smile.
Epic is an Electronic Health Record (EHR) used in hospitals all over the country. If you work in healthcare you know who they are. Epic is the top EHR system in the U.S. and they continue to gobble up market share.
According to the Epic website, the pharmacy information system (PhIS) inside Epic is officially known as the “Willow Inpatient Pharmacy Systemâ€. However, I commonly hear it referred to as simply Willow.
Over the span of my 19 year career I’ve used several pharmacy information systems, but never Willow. For whatever reason the hospitals I’ve worked in have used other EHR and/or pharmacy system vendors; GE, Siemens, MEDITECH, IDX, etc. Recently I had the opportunity to spend a couple days learning how to use Willow. I was pretty excited. I’ve heard a lot of good things about Willow, and some bad. I’ve been wanting to get firsthand knowledge for quite some time.
Disclaimer: These are my initial impressions. Two days of training isn’t nearly enough time to learn all the ins and outs of a pharmacy system. I’ve recently accepted a position where I will be using Epic, albeit not in a full-time capacity, so I’m sure that my thoughts and opinions will evolve over time.
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I’ve had reason to think about Electronic Health Records (EHRs) these past few weeks. There is a lot riding on their success or failure. There’s no question that EHRs will be the future of all documentation in healthcare, but I’m not convinced that healthcare is ready for the transition. At least not yet.
The potential advantages of EHRs are many. In theory they offer real-time information, integration of many systems across a single platform, the ability to store, access and manipulate massive amounts of data (“business intelligenceâ€, analytics, “big dataâ€, etc), they provide information that follows a patient regardless of where they go or who they see, the offer potential for patients to view, edit, use, and add to their own medical information, and so on.
These are all good things. If only the potential was reality. The current state of EHRs is far from their future potential.
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EMR & HIPAA: “Yesterday at the Digital Health Conference I had the chance to catch up with George Cuthbert from Medent. He’d emailed me a few months back about the potential benefit of Windows 8 in the EHR world and the deep integration of Win 8 that they’d been working on to leverage the unique abilities of Windows 8 for their EHR users.
I admit that since I’ve become more of a health IT blogger and less of a techguy, I haven’t kept close track of all that was happening with Windows 8. I knew that it was designed to incorporate touch as a major focal point of the new Operating System and I knew that it was Microsoft’s attempt to integrate the best of touch together with the advantages of data input using a keyboard and mouse.
Based on the short demo that George did for me of Win 8 and the Medent EHR, it has some real promise. In fact, as the title suggests, I think that if an EHR vendor does it right this could solve the issues that so many EHR vendors have of trying to create an iPad EHR application.â€
I’ve always thought that the Windows OS would be ideally suited over iOS and Android for EMR/EHR use because it is the native platform used by a majority of healthcare systems in the United States. Why continually reinvent the wheel when all you do is delay innovation? That’s what’s been going on in healthcare for the last several years when it comes to using tablet technology. Everyone has fallen in love with products that offers less functionality today than my tablet PC did nearly a decade ago. It’s odd when things turn out like that. People tend to get easily distracted by shiny objects. It happens.
The EHR software described at the EMR & HIPAA site can be found in the Microsoft Store. It’s called EMR Surface. More information can be found at the Pariscribe website. It looks interesting, but one can never tell whether or not something is usable by simply looking at it. I’d be interested to hear whether or not anyone has used it and what their opinion is of the system.
A recent article in the Journal of American Informatics Association (JAMIA) takes a look at note-writing practices of medical residents while using an electronic health record (EHR) system. Through the use of time-and-motion studies the authors concluded that there was “a high level of fragmentation of documentation activities and frequent task transitions [when using an EHR].†Not really surprising when you consider that most EHR systems simply aren’t designed with the needs of the end user in mind. In addition it is difficult to use an electronic system in an attempt to mimic the act of taking notes using pen and paper. I’ve struggled with that for years. The thought process is different.
Clinical documentation: composition or synthesis?
Mamykina L, Vawdrey DK, Stetson PD, Zheng K, Hripcsak G.Department of Biomedical Informatics, Columbia University, New York, USA.
OBJECTIVE: To understand the nature of emerging electronic documentation practices, disconnects  between documentation workflows and computing systems designed to support them, and ways to improve the design of electronic documentation systems.
MATERIALS AND METHODS: Time-and-motion study of resident physicians’ note-writing practices using a commercial electronic health record system that includes an electronic documentation module. The study was conducted in the general medicine unit of a large academic hospital.
RESULTS: During the study, 96 note-writing sessions by 11 resident physicians, resulting in close to 100 h of observations were seen. Seven of the 10 most common transitions between activities during note composition were between documenting, and gathering and reviewing patient data, and updating the plan of care.
DISCUSSION: The high frequency of transitions seen in the study suggested that clinical documentation is fundamentally a synthesis activity, in which clinicians review available patient data and summarize their impressions and judgments. At the same time, most electronic health record systems are optimized to support documentation as uninterrupted composition. This mismatch leads to fragmentation in clinical work, and results in inefficiencies and workarounds. In contrast, we propose that documentation can be best supported with tools that facilitate data exploration and search for relevant information, selective reading and annotation, and composition of a note as a temporal structure.
CONCLUSIONS: Time-and-motion study of clinicians’ electronic documentation practices revealed a high level of fragmentation of documentation activities and frequent task transitions. Treating documentation as synthesis rather than composition suggests new possibilities for supporting it more effectively with electronic systems.J Am Med Inform Assoc. 2012 Nov 1;19(6):1025-31
The New York Times: “Computerized patient records are unlikely to cut health care costs and may actually encourage doctors to order expensive tests more often, a study published on Monday concludes.
…research published Monday in the Journal Health Affairs found that doctors using computers to track tests, like X-rays and magnetic resonance imaging, ordered far more tests than doctors relying on paper records.
The use of costly image-taking tests has increased sharply in recent years. Many experts contend that electronic health records will help reduce unnecessary and duplicative tests by giving doctors more comprehensive and up-to-date information when making diagnoses.
The study showed, however, that doctors with computerized access to a patient’s previous image results ordered tests on 18 percent of the visits, while those without the tracking technology ordered tests on 12.9 percent of visits. That is a 40 percent higher rate of image testing by doctors using electronic technology instead of paper records.â€
I can’t say that I’m surprised by this. I remember something similar when I was working as the night pharmacist at Salinas Valley Memorial Hospital in Salinas, California. Physicians that were using pre-printed order forms to admit patients – now considered the standard of practice – almost always wrote for more PRN medications than those that didn’t use pre-printed order forms. We used to call them “don’t call me orders†because they covered every possible what-if for the patient, i.e. what if they have pain, what if they get a fever, what if they get indigestion or constipation, and so on. And why did they do that? Because it was easy to check a box, that’s why.
EMR Daily News: “Shareable Ink®, an enterprise cloud computing company that transforms paper documentation to structured data, today announced three new partnerships with leading EHR vendors that will further the company’s reach in delivering a reliable, portable and easy to implement electronic data capture solution that works with existing physician workflows. The agreements with Greenway Medical Technologies, Inc., NextEMR, VoiceHIT, and an existing partnership with Allscripts, signal the demand within the physician practice marketplace for a flexible technology that can be used in any care setting to help compliance with Meaningful Use (MU) requirements.â€
I think highly of Shareable Ink. I like the concept and think it provides a nice bridge between where we are today and where we need to be. I first mentioned Shareable Ink back in November 2009. It was a good idea then, and it’s a good idea now.
A recent article in Chest1 demonstrates the value of electronic data collection in medication adherence. In this case it was inhalation therapy in cystic fibrosis patients. This type of article is important as we consider the future of electronic health records and where the data for such records should come. Remember, people are notoriously unreliable historians while computers don’t lie.
Selected excerpts from post-gazette.com article:
More and more studies are questioning the efficacy of electronic health records, and the U.S. Food and Drug Administration has begun collecting reports involving electronic health and IT errors, some of which have resulted in death…
“The thing about these systems is that it doesn’t really look like they’re getting any cheaper,” he said. “And the upgrades and the upkeep represents a very significant cost, especially in outpatient clinics.”
Of those, 163 contained mistakes that could have led to “adverse drug events.” Most errors were mistakes of omission — a doctor left out an important piece of data.
Notably, this “is consistent with the literature on manual handwritten prescription error rates,” the report said. But the larger point is computerized systems do not automatically outperform paper ones. [referring to:Â Errors associated with outpatient computerized prescribing systems. JAMIA, 2011; DOI: 10.1136/amiajnl-2011-000205]
For an industry that relies on data and evidence-based measurements to make decisions on the clinical and pharmaceutical side, there isn’t a lot of evidence supporting the notion that electronic health records produce cheaper care or better outcomes.
I think the article outlines some of the significant problems that need to be addressed before a truly effective EHR system can be utilized. We’re forcing the healthcare industry to implement a technology that they’re simply not ready for. The IT infrastructure in healthcare is built on marbles and is still years behind the consumer market in all but the most advanced facilities. In addition we continue to struggle to standardize information. We first need to understand what the information will look like before we begin forcing everyone to use it.
There’s no question in my mind that sharing information across the healthcare continuum is paramount to providing safe, efficient, cost effective healthcare. However, there are some key pieces of the puzzle missing. Without those pieces we’re not going to get the whole picture, and that’s a problem.
EHR outlook: “Patients are still worried about how secure their data will be when stored in an EHR systems, a new study suggests. Xerox Corporation found that of 2,720 poll respondents:
I’m not surprised by the numbers. In general people are afraid of change and the unknown. With that said, I think all you need to do is walk a patient through the paper processes that we use now to give them some insight into how bad things really are. Stolen and lost personal and medical information is a major problem within the current healthcare system. It’s not uncommon in any given week to hear about patient records that have been lost or stolen. And as far as misuse of information, well lets just say that’s all too common as well.
The advantages to an EHR outweigh the concerns listed above. Just sayin’.
