EMR / Labs call for input

Okay folks, I’m going to call on your wisdom and ask that you help me improve our EMR.

I noticed right after our EMR started, with Rh testing: I would look in past labs to see if my patient (pregnant with vaginal bleeding) had a documented Rh.  Yes, it turns out, many had had more than 5 (even when positive), because we had no way to access those prior tests.  Now we do, with the EMR.

I want to take this a step further, and make a list of tests we can start ‘flagging’ that don’t need to be repeated because some things don’t change.  No sense doing the same thing over and over if the result’s going to be the same.

Here’s my first pass:

  • Rh (if positive)
  • G6PD
  • HIV (if positive)
  • Sickle Cell screens
  • All those heritable clotting disease tests (Factor V Leiden, Protein C, Protein S, etc).

I wouldn’t restrict anyone’s’ ability to re-order (confirmatory test) but would have the prior result pop up in the ordering box for that test.  Usually these are re-ordered in ignorance that it was done before.

Here’s a place an EMR can actually contribute to cost savings!

Please put your recommendations for other tests that don’t need repeating in the comments.  I’ll make a compilation post when other recommendations peter out.

Our EMR is very dedicated

Even when it crashes:

CannotQuit (it says “Cannot Quit”).

One of the unintended downsides of the EMR

I like EMR’s but realize there’s a downside.  Like this, for instance:

Hospital: 15 fired for looking at octuplet mom’s file – CNN.com
(CNN) — Fifteen employees were fired for improperly accessing medical records of Nadya Suleman, the mother of octuplets, a Kaiser Permanente spokesman said Monday.

My particular EMR has a feature called ‘breaking the glass’ that requires an acknowledgment and both a user name and password that match to access a record you didn’t start yourself.  It can be a hassle, but hopefully it’ll help cut down on this sort of invasion of privacy.

Those drug-interaction warnings sure are irritating | Booster Shots | Los Angeles Times

Those drug-interaction warnings sure are irritating | Booster Shots | Los Angeles Times
Those drug-interaction warnings sure are irritating
10:30 AM, February 10, 2009

One can imagine how electronic drug-prescribing systems could be annoying to doctors — all those warnings about potential interactions and allergies and whatnot when all you really want to do is give a patient a drug he or she needs and be done with it. It’s probably easier to just ignore the blasted alerts and keep going.

That seems to be what’s happening. In a study published in the Feb. 9 issue of the Archives of Internal Medicine, most doctors simply shrugged off the warnings issued by their helpful electronic systems.

Out of almost a quarter-million medication safety alerts produced during the study period, the doctors involved accepted only 9.2% of the interaction warnings and 23% of the allergy warnings. In other words, they ignored more than 90% of the drug interaction alerts and more than 75% of the allergy alerts.

As a fellow practitioner of blog-snark I’m impressed with the slant of the article, that doctors treating patients ‘ignore the blasted alerts’ and ‘shrug[ged] off warnings’.  As a doctor who uses a very good EMR tool daily I can tell you that a terrific number of the medication alerts given by the system are of such exceedingly minimal value they need to be over-ridden for accurate and adequate patient treatment.

For instance, if a patient reports an allergy to ‘Demerol’ in our EMR, giving Zofran (an anti-emetic) yields an allergy interaction.  It’s a theoretical connection and not founded in reality, or practice.  Want to prescribe pain meds for a patient being admitted? We get an alert that the patient has already been prescribed pain meds, even though the earlier meds were given in the ED (only) and the order in question is for inpatient treatment.  Very helpful.

The LATimes article doesn’t indicate if any harm came to any patients (I certainly hope not), but the finding that practicing docs didn’t heed a zillion electronic drug warnings just means the electronic systems need to tell us when the sky is actually falling, and not squawk continuously without cause.

How Docs can continue to have illegible records in an EMR

Make our own font based on your handwriting:

DIY: YourFonts Turns Your Handwriting Into a Personlized Font
YourFonts is a web-based service that turns your handwriting into a TrueType font for free. If you have a printer and scanner, nothing can stand between you and the awesomeness of your own script.

What could go wrong?

In the interest of full disclosure on the EMR

It occurs to me I have exposed myself to a potential charge of a conflict of interest here, and want to clear the air.  (Dang, and right after having been okayed for the Healthcare Blogger Code of Ethics, proudly displayed in the right sidebar: they may want it back, and I’m not kidding about that).

I hadn’t meant to talk about which EMR we’re using, but in the excitement I did.  We’re using EPIC, which is pretty good, and I’m perfectly happy with 85% of it, and the rest we all want to tweak.

I am a paid consultant to our hospital ownership groups’ EPIC steering committee, and have input into what goes into order sets, etc.  It takes 2 hours once a month, so I’m not going to retire (or even vacation) on the income, but I do get money for working on the project.  I can tell you  I signed an NDA about what we do specifically, I don’t own stock or get any other money from these efforts, and I don’t work directly for EPIC on this.  I don’t want my discussion of our EMR to cross any ‘talking up a commercial product that he’s getting money from’ line, thus the disclosure.

So now you know.  I don’t consider it a conflict, but you can be your own judge of that.

How much do we like our new EMR?

We’ve been all electrical in our ED for nearly four days now.  How do we like it?

Tonight, we couldn’t get the registration system to talk to the EMR, and it was decided “Well go pack to paper”.  None of us was happy about that.

Really.  4 days in, we’ve seen the light, and none of us wanted to go back to paper.

Terrific, actually.

My first day with an EMR

Is tonight (Friday night).  Our overnight shift, which on a Friday night can run from busy to very very busy.

The ‘switchover’ is at midnight, though for various technical reasons we won’t be fully electronic until after 3AM, so it’ll be a mixed environment of paper and electrons.  I volunteered for this shift, so it’ll be a lot of fun.

I am cautiously optimistic, and we’ve given ourselves a big advantage: we’ve doubled up on scribes and we’ve “borrowed” them from places that already use the EMR (we’re on Epic, but it could be any system), and that should ease the transition.  That, plus all the official tech helpers coming for the first 15 days.

We’re pretty well prepared for this, though it’s been described as starting a new job: I know the medicine but the ‘how’ and the ‘what are the cues we’re done’ are different.  It’s billed as being mildly or very inefficient, though that’s supposed to get better with experience.

I’ll let you know.

Update: The transition wasn’t smooth.  There were much longer delays at each step that had been anticipated, the end result of which was the our 4AM doc was really the first doc to see the majority of their patients on the EMR.

It didn’t help that the ED was a total zoo.  People will not stop having emergencies for us to smooth over our little technical problems.  Imagine.  (Yes, that was sarcastic, DWL).

Google chases Microsoft over online personal health records

Google unveils plans for online personal health

October 17, 2007 (Computerworld) — Less than two weeks after Microsoft Corp. announced plans to support online personal health information records, Google unveiled plans to follow suit.

Marissa Mayer, Google’s vice president of search products and user experience, said Wednesday here at the Web 2.0 Summit that Google plans to support the “storage and movement” of people’s health records.

Although she provided only scant details on the effort, she noted that Google became interested in the personal health record market as it watched Hurricane Katrina take aim at the Gulf Coast and all the paper-based records stored in various medical offices and hospitals in the region.

“In that moment it was too late for us to mobilize,” Mayer said. “It doesn’t make sense to generate this volume of information on paper. It should be something that is digital. People should have control over their own records.”

Wow, Google does vaporware? This is a lame attempt, and invoking Katrina a) is a cheap rhetorical gambit and b) points out that even if it were true they’ve had over 2 years to come up with their answer, and it’s not even at a Beta stage?

Weak response from Google. Embarrassing, really.

Microsoft and the EMR

To swipe a lead-in from the WSJ Healthcare Blog, “Microsoft finally beat Google at something”.

From the straight reporting:

The Wall Street Journal Home PageA new Microsoft Web site announced Thursday, called HealthVault, includes a secure way to upload data such as blood-pressure readings so consumers can keep record of their health information. The “personal health center,” as Microsoft calls it, is designed to allow consumers to share such information with physicians and other medical professionals. The site also offers Internet search and a Web page for viewing and organizing articles and other information on health.

HealthVault is the latest step in a two-year effort by Microsoft to build software and services in the health field, targeting both consumers and health-care organizations. The company has quietly built a group of programmers and professionals with related expertise, and purchased several companies to help speed its move into healthcare.

I think this could be a very important development toward a more-universal EHR.  The current focus on internet-connectible BP monitors is weird, and what I’d like to see it used for are things like your latest EKG, etc.  I would guess major clinics and hospitals will partner with MS as a ‘value-added’ feature to entice patients to use their health system (“we’ll make your results available to all your doctors 24/7” sound more reassuring and less like a threat to privacy).

We’ll see how this plays out, and I think it’s got a lot of promise (and some talented deep-pockets behind it), so here’s to MS for getting out in front on internet storage of health care information.

Medpundit and Kaiser’s EMR


Birth Pangs: There aren’t too many hosannas being sung to electronic medical records at Kaiser these days:

Kaiser Permanente’s $4-billion effort to computerize the medical records of its 8.6 million members has encountered repeated technical problems, leading to potentially dangerous incidents such as patients listed in the wrong beds, according to Kaiser documents and current and former employees.

At times, doctors and medical staff at the nation’s largest nonprofit health maintenance organization haven’t had access to crucial patient information, and system outages have led to delays in emergency room care, the documents show.

There’re a lot of ‘ifs’ in the upside to the EMR.

Corporate Suicide Alert

Fast on the heels of my endorsment of PEPID over Epocrates comes this stunner, from Epocrates (in my email):

We think it’s important to let you know that many Palm® OS and Windows Mobile® (Pocket PC) OS software applications, including all Epocrates products, cannot at this time be installed or synced via computers with the new Windows Vista operating system. 

We strongly recommend that if at all possible, you postpone installing Vista or upgrading to a new PC with Vista installed. 

Since resolution of this problem depends upon software changes by both Palm and Microsoft, we regret that we cannot give you a firm date for a fix.

If you are already using Windows Vista, please review our FAQ for the latest recommendations from our customer support and engineering teams. Read FAQ »

Thank you for your patience and understanding.


The Epocrates Team

Huh?  Did they not know the biggest maker and most aggressive distributor of operating systems was coming out with Vista?

I’m not using Vista (I’ll wait for SP1 before I even look at it), but this seems particularly clueless for a medical software company.

Another EMR growing pain

…what to do with that information you want to keep, but keep in a truly confidential manner.  The Blog That Ate Manhattan discusses it in Notes to Myself.