Discharge Module Wish List

Discharging patients in real-time should be quick, swift, and efficient.  It should not involve a labor intensive, redundant process resulting in unnecessary delay.  Completing the multiple necessary items should be possible with a few routine mouse clicks. 

Unfortunately, many of the EHRs in use today do not understand Emergency department work flow (or physician work flow and thought process in general); as a result, repeated, nested mouse clicks are often used, and these can take up to 10 minutes.  This time is better spent in actual patient care.

Indeed, many electronic health record systems do not distinguish the needs of the particular care-setting in which it is used.  Most importantly, emergency department, urgent care and outpatient settings have some similarities in their discharge processes, but for inpatient settings, discharge is necessarily more complex, especially due to recent regulatory penalties regarding re-admissions.  Hence, a "one-size fits all" software solution where inpatient discharge procedures are imposed on care-settings with rapid outpatient turnover, do not work!

One big issue with many EHR implementation is physician activities and work flow are poorly understood by IT developers, which may cause unnecessary redundancy in tasks when using the program.  Even Amazon and Google understand human ergonomics better than has been demonstrated overall by the EHR industry.  For example, instead of data accumulated by the provider being automatically transferred to the discharge information (i.e. follow-up physician, prescriptions, date of follow-up), complex actions, such as copy and paste or (worse) scanning, are employed.  This also happens in the reverse direction where data put into the  discharge paper-work is not auto-transferred, or even appended, to the medical record.  This leads to double work and difficulty in figuring out what actually happened, when reviewing the chart, if such a review of everything done is even possible.

And then, the patient often receives up to 10 pages of information with little hope of retention even if read.  It should be kept in mind that there are two basic pieces in the discharge process:  1. Instruction including follow-up plan- printed, with corresponding education provided personally by the physician and nurses, 2. Prescription - electronically created and transmitted Rx, or printed and given to the patient- including such necessary pieces as work or school excuses.

The Tenuous Balance

The EHR, Safety, and Cost

Excessive regulation & Red Tape = Increased Cost & Impaired Workflows

 

 

As the electronic Health Record marches full force to alter medicine completely, there will be some consequences.

The diagram above represents the battle between goal of patient safety, which attempts to use the EHR to solve problems, control behavior, and create new behaviors.  The problem is the end user is rarely consulted and or considered.  Government regulation forces companies to create products that decrease the ability of the end user to seamlessly integrate into their practices without the use of aids (scribes, assistants, computer jockeys, and voice activated technology, etc.).  The institutions and private practice are using EHR 1.0 and they really need EHR 2.0.  The financial commitment and government subsidies (meaningful use) create an environment of inertia that impedes rapid change to "best of breed" products.

The Right Click Dilemma!

What is the difference between a person who understands computers and the rest of us?  It is the ability to understand that programmers love to right click to create endless contextual menus.  these menus are interpreted by IT people because 1- they know they exist and 2- they read and act on these menus.  The rest of us stare in silence, stupidity, or disbelief.  How did they know"that"?  Why would they hide the menu from us?

When dealing with many Electronic Health Record systems, the right click is your arch nemesis.  You had endless hours of training, but still cannot remember what to do next.  You did not realize that you can right click something or everything and multiple hidden menus appear with the answer.  When you have suffered through multiple minor epiphanies and created multiple "work-a-rounds" and/or "favorites" the program becomes less onerous.

The real solution is end-user friendly Electronic Health Record do not rely on a right click, multiple hidden menus, work-a-rounds, and favorites to utilize.  The user should be able to look at the screen and intuit what to do next.  What is painfully obvious to the "programmer" is not obvious to all end users.

If the program takes endless hours of training, needs "super-users", and you forget things after only 1 week, the endless psychological toll it takes on the users is profound.  This leads to lost productivity, unhappy employees, and general disenchantment with the whole process.  The Electronic Health Record has many potential benefits, but this is often lost in the battle to process efficiently.

Artificial Intelligence

Artificial intelligence (AI) is the intelligence of machines-robots and the branch of computer science that aims to create it. AI textbooks define the field as "the study and design of intelligent agents" where an intelligent agent is a system that perceives its environment and takes actions that maximize its chances of success.  Wikipedia defines it as "the science and engineering of making intelligent machines."

 

One of the greatest values of the Electronic Health Record is the seamless addition of AI to the user’s own brainpower. This is manifested in various ways.  Below is a list of potential AI elements, some already present to some degree, in various systems:

1. Drug interactions 
2. Drug Allergies 
3. Recommended “state of the art” treatment plans when a sign, symptom, lab result, x-ray results, EKG data, evaluation of PMH, SH,FH, working diagnosis are noted by the computer. The computer does a risk factor analysis of the data and creates a differential diagnosis. 
4. Warnings --
1. Errors in dosage 
2. Errors in medications 
3. “Are you sure you want to discharge this patient” with this constellation of data points? 
4. Wrong patient-in congruent data entry 
5. Reminders -- 
1. Lack of documentation completion 
2. Lack of signatures 
3. Attention to attestation of information 
4. Core measures, PQRS, on-going studies  
6. Active rather than passive resource tool 
1. Who’s on call 
2. Phone numbers 
3. Timing of interactions of consultants/i.e Cardiology consult might be beneficial 
4. Recommend evidence based resources or wed sites if more info is needed 
5. Calculates various scores (Glasgow Coma Scales, PERC score, TIMI scores) that are clinically relevant
7. Feedback --
1. How much money did you spend to attain this end-point? 
2. What was clinical outcome of admitted patients? 
3. Report on rechecks and bounce-backs 
4. Admission rates 
5. Times-LOS, door to doctor, doctor to decision 
6. Benchmarking your performance within your practice, local hospitals, and national data

The addition of AI should be embraced not avoided. Theoretically, it could make your difficult job less stressful and more efficient.

However, one should always keep in mind the meaning of the words “artificial” and “intelligence.”   These do not inherently include the terms “wisdom” or “judgement,” the standards a physician is always held to, medically and legally. Thus a physician has the obligation to accept or reject the advice of the machine. In either case, the physician is ultimately responsible. While we are not yet confronted with the independence of the computer, as depicted by Hal in Stanley Kubrick’s 2001 A Space Odyssey, one might best remember that it was astronaut Dave who disconnected Hal’s power supply to save his own life. We may, at times, need to do the same.

Prolonging Your Career!

Recently I have been unable to work full-time due to medical issues.  However, it is not due to any chronic or underlying condition i.e. DM or CAD, but to a relatively sudden onset musculoskeletal breakdown.

If you saw the overweight, balding, shuffling, poor posture, and moving slowly provider, THAT WAS ME!

It has become apparent to me, that proper physical conditioning is an absolute requirement for our busy, stress-laden jobs that require of us 5 miles of walking per shift.  I worked out in a linear fashion i.e. elliptical, treadmill, and stationary bike 3-4 times/week faithfully for at least 1 hour sessions.  This did not prevent my problems.

I went to the orthopedic specialist for help with this new issue, and the first thing he recommended was taking up yoga to loosen up my totally “stiff body”.  First attending “restorative yoga” (geriatric yoga where touching your toes means reaching your knees), it was apparent that I should have been doing something like this for years.

After 2 sessions, I could now back up car safely without the use of a camera display or grab things out the back seat easily.  The classes are difficult, but improvement comes with each one.

Everybody worries about their mental health, brain power, medical health but musculoskeletal breakdown needs to be added to the list.  Yoga is a good path; some do Pilates, some intensive stretching; in any case, paying attention to, and managing, muscular flexibility and mobility is key in our profession.        

 

Which EMR Should You Purchase ?

CRITERIA:

1. Certified for meaningful use to offset costs-(includes easy reporting functions to avoid government "clawbacks".)
2. Walk up usability-(the ability to perform various functions with minimal training)
3. Intuitive navigation-(logical, consistent, and labeled)
4. Content designed specifically for the clinical area (specific charting for the Emergency department, urgent care, and/or family practice)
5. Integrated practice management - (scheduling, coding, and billing)
6. E-prescribing
7. Patient Health record (clinical data repository) that tracks Problem list, Allergies, Past Medical History, medication reconciliation, Family History, Social History
8. Ease of training-(3-4 hours vs  longer than 12 hours)
9. The program does not need multiple "work-a-rounds"
10. The use of scribes and voice-activated technology are additive,not necessary to survive

This is the tip of the iceberg. Bottom line, is purchase a product that is designed with the " End-User" in mind.

Practice Management - Requirements For Success

Many individuals are inspired to become entrepreneurs and control their own work destiny.  They are willing to put in the “sweat equity” to be their own ‘boss’.  Opening and running your own practice and or urgent care is a worthy goal but to be successful, the “devil is in the details”. 

Here are some suggestions on how to select a “value added” practice management program that allows one to run an efficient business.

1. Attractive interface that has “walk-up” usability
2. Designed for end-user not programmer
3. Easy, logical navigation
4. Scheduling module that can be customized 
5. Registration module with scanning of  identification and insurance cards capability
6. Instant eligibility notifications for insurance, deductibles, and co-pay
7. Instant access to past visits and  accounts receivable
8. Fully-integrated Electronic Health Record that interacts with the practice management system to capture all CPT codes, ICD-9-10 diagnosis to easily code and send an accurate bill.
9. Certified Electronic Health Record to be eligible for $44,000 meaningful use funds to defray initial costs.
10. Electronic Health Record that has a full database, scanning capabilities, E-prescribing, and is not “hated” by the end-user.
11. Coding support and billing functions that allow you to 1. Do your own billing 2. Outsource to a billing company 3. Any combination of the above.
12. Gives real-time feedback on AR to allow staff to resubmit claims for reimbursement in a timely manner
13. Management reports
14. 24 hours support
15. The cost of the software is offset in savings in the number of FTE’s (full-time equivalents) to run the practice.

Every practice is different, but being efficient and controlling costs goes a long way toward a positive ROI (return on investment).