Monday, December 5, 2011

Doctor Aware” - The Integration of Nursing Notes and Physician Documentation

How does the provider keep track of the nursing notes with the use of purely electronic medical records?
Theoretically, in the “paper world” the provider would read all the nursing notes and then comment or appreciate the content. In reality, the provider rarely reads more than the initial triage assessment and nursing note. The rest of notes are kept with the nurse and usually completed long after the physician is finished with their documentation. Physicians who document after the fact on their own time, may or may not use or have access to the notes.
In the “Electronic World” the provider rarely has real-time access to the nursing notes with a single mouse click. They have to maneuver around the program to find the data (if it even there yet). Your computer program should have easy access of all data to all providers that have been granted access. This should be accomplished easily and without requiring the user to be a computer expert.

Additionally, how do healthcare providers know when the nursing notes are complete concerning the interaction with a specific provider? The notes can go on and on for “ED Boarders” when the initial provider is long gone. This is also true for discharged patients when the nursing notes are done long after the fact.

My favorite nursing notes are “Doctor aware” and “Doctor notified”. About what?????

The EMR we use attempts to solve some of these problems with simple interface like a “tab button” that allows quick access.

Wednesday, November 9, 2011

Take Me Out to the Ball Game

The role of the ED physician has dramatically evolved over the last 10 years. The perfect ED provider must be a combination of Dr. Marcus Welby from ABC’s 1970’s hit show, Dr. Leonard “Bones” McCoy from Star Trek, and the staff from the 90’s TV show ER.  Doctors are expected to be good-looking, decisive, charming, and always get it right in the end – all in less than 48 minutes (barring extra commercials.

This is obviously a difficult task for us mere mortals. The present model has the physician perform every role for every patient. Assigning a provider to the intake (formally known as triage) has started to break down the classic role.

To take this concept one step further ED staff members can be broken down to using a sports analogy –a baseball team.
  • Starting pitcher—triage—get the ball rolling—start the evaluation ASAP
  • Middle relief—fully evaluate the patient and develop treatment plan
  • Long relief—on call to deal with massive volume shifts
  • Closer—makes the final compact with patient, family, admitting physician, consultants in a very timely manner.
  • Designated hitter—provides critical care to free up rest of staff
  • Manager—medical director guiding flow and dispute resolution
  • Broadcaster—public relations specialist in Press-Gainey and PRC scores
  • Statistician—documents all the data for medical-legal, reimbursement, and time frames.
  • Rest of Team—The key to success is the support staff - nursing, administration, trainers, secretarial staff, etc.

In conclusion—a single provider even with an all-world team members is hard pressed to perform all these tasks.

Monday, October 10, 2011

The Art of Medicine: Evidence-Based vs. Evidence-Enhanced

Medical care has evolved from using the individual practitioner’s training belief system, and own personal bias to using data, studies, and evidence to make appropriate decisions. This more scientific approach has yielded better results and more rational treatment programs.

However, in the mantra of “double-blind-controlled study," there is another side of medicine that needs to be addressed. This is the “Art of Medicine”.

Medical care not only includes scientific assessments and treatment protocols but also the human side. Patients come for the best scientific care but also for compassion, empathy, measured opinions, and guidance.

The Electronic Health Record (EHR) gives access to the data, but not the whole story.

By combining “evidence-based medicine” and the “art of medicine” you will achieve “evidence-enhanced medicine” giving the patient a holistic approach for which they are grateful. There is a reason other than scientific medical care that patients are nostalgic for their “own doctor."

Monday, October 3, 2011

Why Your EHR is "Creepy"

The definition of creep according to Wikipedia is the tendency of a solid material to slowly move or deform permanently under the influence of stresses.
The software you are dealing with is in a constant state of flux leading to multiple changes that may inadvertently lead to user dissatisfaction.

1.      Version “creep”—constant upgrading of the software with leads to potentially unwanted changes.
2.      “Creeping Elegance” ---- developers seeking the “HOLY GRAIL” of perfect software while detracting from its fundamental utility.
3.      Government “Creep”------ new rules every month that forces the software to make changes that may or may not be in the actual user’s interest.
4.      Payment “Creep”---“meaningful use” is a classic example of making programmatic changes to reimburse the client for their investment. Whether the purchaser recoups their investment remains to be seen.
5.      “Enterprise Creep”---- the institutions purchases an enterprise computer system (full hospital system) not designed for the particular end-user ( i.e. –no specific ED module). This may force a relatively satisfied user to reinvent the wheel.

The goal is to find an end-user friendly product that helps the provider rather than putting up a spider web of obstacles.

Monday, September 19, 2011

2 Hour Length of Stay in the ED - Would You Like Some Fries with That?

In the ED community there is a new marketing tool—30 minute or less no-wait ED service.

The implication is a provider (physician, PA, or NP) will greet you- a la the Wal-Mart greeter- to begin the service relationship. There are billboards, internet advertising, etc. that proclaim your care will be improved because it will be faster.

If properly conducted where the patient is fully evaluated, there should be significant PRC or Press-Ganey score improvements.

I would prefer to see the metrics based on speed, quality, and outcome.

This would be the “ED Value Plan” that encompasses speed, efficiency, communication, and quality. (9 out of 10 members in my family would choose this plan).

The provider will discharge, admit, or carefully discuss with the patient and family the “Battle Plan” for disposition at the 2 hour mark.
1. Discharge prior than 2 hours
2. Admit prior than 2 hours
3. Discussion with patient.
         a. Outline the timeframe
         b. Discuss need for more tests (CT abdomen)
         c. Waiting for consultant
         d. Providing more treatment to avoid admission (i.e. fluids, 2nd set of              troponin levels

Tuesday, September 13, 2011

Guest Blogger - Jim Tate: EHR Incentives Drop Dead Dates

Several times a week I am asked the same question by providers and vendors. The question takes different twists and turns, but it all gets down to one core concern. To put it in the crassest terms, here it is. “What is the absolutely last drop dead date an eligible professional can meet the CMS EHR Incentive Program requirements and not leave any money on the table?” OK, now that the question is clear, let’s answer it once and for all.

For Eligible Professionals there are two CMS programs, Medicare and Medicaid, which incentivize EHR use. An EP must select one of the programs for participation, and is allowed to switch programs once. Let’s take a look at Medicaid first. 2016 is the “Last year to initiate participation in the Medicaid EHR Incentive Program” and 2021 is the “Last year to receive Medicaid EHR Incentive Payment.”

Jim Tate is a nationally recognized expert on the CMS EHR Incentive Program, certified technology and meaningful use and a partner in HITECH Answers. He is also author of The Incentive Roadmap® The Meaningful Use of Certified Technology: Stage 1.

HITECH Answers -
To purchase Jim Tate's book "The Incentive Roadmap The Meaningful use of Certified Technology: Stage 1 visit:

Thursday, September 1, 2011

Medication Reconciliation and E-Prescribing

E-prescribing is a certification requirement for out-patient clinics and urgent care facilities for EHRs to obtain "meaningful use" monies from the government. E-prescribing is desirable for patients, but its real objective is medication reconciliation.

This process is intended to be convenient for the patient; however, there is also an underlying goal to achieve medication reconciliation. The goal of medication reconciliation is important, but it is also time-consuming and labor intensive.

The problems associated with e-prescribing are:
  • Who is going the input the info?
  • Who is going to keep it updated?
  • What is the time frame?
  • Accuracy depends on patient and data collection

E-prescribing can only be accomplished if medication reconciliation is performed by the E-prescriber and his/her software. This puts the burden on provider and his/her staff.

Thursday, August 18, 2011

Liability and the Electronic Health Record

The electronic health record (EHR) should lead to patient safety and help minimize liability, but there are built in-traps that come with it. These traps can be subtle and can lead to quality reviews and potential liability for the provider.

Potential Traps:

1.      Timestamps—all over the place. These can be recorded but may not necessarily reflect true clinical activities. Not paying attention to document when things really happened.
a.      EKG was signed off 1 hour after the patient was already in the cath lab
b.      Clinical course out of sequence with CPOE and nursing notes
c.       When a consultant was called  and their advice

2.      “cut and paste”---“cut and paste”  Copying and pasting information can be as harmful as it is helpful. Information can easily be repeated or copied into the wrong section.

3.      “Cookie-cutter” charts that are  loaded with data that may or 
      may not have occurred.

4.      Inability to easily access nursing notes- and the converse. The world famous “DR aware” note.

5.      Not knowing the status of treatments orders, even though the computer says they are signed off.

6.      Clerical errors on the CPOE.

7.      Not creating a work-flow that emphasizes timed data points that affects LOS/time to provider/time to decisions. If the providers are not “clicking” the tracking board, the     data suggests inefficiencies. Hospital management only looks at the data and rarely any excuses.

8.      Timelines are much easier for the plaintiff's attorney to create, which may look jumbled even though the reality was different.

9.      Not checking the output on key areas to make sure it reflects what was supposed to be communicated.

10.  Receiving a transfer patient with “40” pages of computerized documentation and missing the key.

Dictation Software - The Best Way to Avoid Traps:

In the clinical course, use dictation software or voice-activated technology to create a recap of all the events. I prefer to use Dragon Medical dictation software. A quick summary will indicate the battle plan, the response, and the disposition.

Paper, dictated, and electronic charts are all good for the initial evaluation and the disposition, but the clinical course is usually murky and left up to the imagination.

Tuesday, August 2, 2011

Does Medicare Reimburse for “Pharmectomies?"

Living in Florida, we see large number of elderly, chronically-ill patients with multiple medical problems.

These patients have multiple providers – primary provider, ED provider, nursing home provider, hospitalists, consultants, etc.

This leads to multiple treatments and prescriptions that have endless interactions and reactions.

After the medication reconciliation is completed on the Electronic Health Record (EHR), the process does not simplify.

So we have changed our process at my ED. Now if your medication bag weighs more the 5 lbs., we admit that patient to the hospital for a “Pharmectomy” - we eliminate all the medicines and start over. 

We are currently searching for a “surgical code” for this procedure as the reimbursement might be higher. 

Thursday, July 28, 2011

Why has the Most Expensive Person in the Room turned into the “Data Jockey?"

In the old days, the healthcare provider would scribble a few orders, write a brief note and be done with the paperwork.

Times have changed.

When using a tracking board, CPOE, and Electronic Health Record, the healthcare provider is now burdened with inputting endless data to obtain accurate:
  •               Through-put times
  •               Door-to-balloon times
  •               Stroke alert data
  •               Time of EKG reading
  •               Time of consultation
  •               ETC., ETC., ETC. – The list is endless

This does not include the history and physical, clinical course, medical decision making, procedure notes, critical care documentation, Rx, and discharge paper work, and etc.

What kind of help is available?
  • Scribes work but are expensive.
  • Voice activated input like “Dragon Medical” dictation software   are worth every penny
  • A data gatherer who sets up record with everything except  HPI and MDM (college students are inexpensive)
  • You could do everything after the fact but times are inaccurate depending on the program used. This practice also burns providers out and increases the need for mental days off.

The provider is “bogged down” with endless paperwork regarding data entry which leads to lost productivity and less real-time patient contact and care. Switching to an EHR will take some adjustment time but it will help healthcare providers adjust to the role of  “data jockey.”

My ED uses a combination solution.

  • The king pin is an EHR charting program, XpressCharts EHR, that I helped developed. The program is user friendly, has the ability to created “favorites,” is dictation software compatible, and has a minimal need for user computer knowledge. The program can also be used easily without adjuncts.
  • Voice activated support that allows users to dictate in all text boxes. The EHR used, XpressCharts EHR, is set up to easily allow this which eliminates most typing.
  • College students serve as “data-go-fors”.

Monday, July 18, 2011

Treatment Protocols, Cookbook Medicine, and the Food Network

Treatment protocols for Sepsis, ACS, STEMI, GI Bleeding, Coagulopathy, Hypertension, Pneumonia, etc. have been created to aid the clinician in giving the best evidence-based treatment plans. These can be attached to the CPOE and be used easily. The advantages are not “reinventing the wheel”, using UTD treatment plans or bundles, and give the support staff parameters of how to adjust the medicines per response of the patient.
Criticism has arisen because this is cookbook, formulaic medicine that is unnecessary and intrusive, making the individual feel his/her plans are 
Our ED group has chosen to emphasize protocols for critical patients to give the patient the best statistical shot at success.

Being a fan of the Food Network and their creativity, it is apparent that cooking is a function of chemistry.  All the great cooks use basic protocols (recipes) to get started and adjust them with nuance and art.

The same can be done with medical protocols when they are used as a basic approach. The “Art of Medicine” (experience, knowledge, empathy, spirituality, gestalt) can then be added to make the protocols “state of the art”.

Tuesday, June 28, 2011

Maximize Your Personal ED Efficiency

Do you carry a heavy work load in the emergency department? Do you feel overwhelmed?  Do you find yourself asking:  What should I do first?  What should I do next?  Would this be easier with an Electronic Health Record? 

It’s important to have a battle plan to achieve maximum ED effectiveness.

The EHR has helped me achieve ED efficiency.  I’ve worked full time as an ED physician since 1978 with 150,000 clinical visits, 6-7% mid-level support and 11-12 RVU’s per hour.

My Personal Efficiency Goals are:
  • 2.3 - 2.5 patients/ hour
  • No overtime
  • No down-coding
  • Limit liability
  • Contact patient within 30 minutes of arrival
  • Discharge within 120 minutes
  • Make Admission decision within 120 minutes

To achieve these goals, I follow a theory of compartmentalization.

The Theory of Compartmentalization

1.     Approach each patient with all the data that is available from triage, old records, rescue, and patient personal profiles.  The two to three minutes you spend to do so will save a great deal of time and focus your evaluation.

2.     Walk in the room with the EKG and the old EKG

3.     Determine why the patient is there.

4.     Make a game plan with the patient, nurse, and family within time frame (avoid unsolicited visits from family members to desk)

5.     Order tests and treat patient in a parallel paradigm.  Most treatments can be completed while tests are being performed.
a.     Stable patients
                                                              i.      Give appropriate treatment, if needed
                                                            ii.      Get your extenders to perform all procedures (if available)
b.     Unstable patients
                                                              i.      Have a game plan already in place for diagnosis (reinventing the wheel takes time and inspiration)
1.     Prearranged  treatment protocols
a.     ACS/STEMI
b.     Sepsis
c.      DKA
d.     GI bleeding
e.     Hypertension - Results are parameters for nursing to adjust medications without asking or forcing the provider to “hover”
                                                            ii.      Notify your consultants early - get help

6.     Know the risk factors and red flags for standard chief complaints

                                                          iii.      Treating Hypotension - can always give O2 and fluids while trying ascertain the cause.  Assume sepsis, if normal cardiac and no blood loss (GI bleed, ectopic, AAA etc.)

7.     Analyze the Vital Signs
a.     Your  Electronic Health Record should list them and then remind you when you identified them in your History and PE
a.     Abnormal vital signs need explanation!

8.     Identify the items that will make the disposition - What is the rate-limiting step?  ASSIGN A COMPARTMENT FOR EACH PT
b.     Recheck them during the encounter and prior to disposition
a.     Need CT results
b.     Need biomarkers
c.      Who is the potential admitting provider?
d.     What consultants do I need to call and when? Now? After what test?

9.     You can usually tell in 1-3 minutes
e.     Who do I need to reassess in 10 minutes or after tests?
a.     Admit
b.     D/C
c.      10% no idea, no clue, run preliminary screening tests and then plan on re-evaluation.  You may have to start over, do not spin your wheels.  Order a sedimentation rate.

10.   Make a decision of how many active patients you can manage at given time.  Maximum is 8-10.

11.    When you reach that level, make some decisions.
                 a.     Review the x-ray and lab data 
                                                             i.      Have all the labs, x-rays, urinalysis been 
                             ordered and sent?
                                                            ii.      Your tracking board should inform you of when tests are complete, the status of blood work (4 of 6 complete), and if x-rays have been performed and are ready for evaluation.
                                                          iii.      PACs should have an icon with a preliminary reading.
                                                         iv.      Critical value notification should be on the tracking board.
              b.     Call the admitting physicians
              c.      D/C the patients.  A standardized prescription writer 
                   and discharge instructions are needed   
             d.     Reassess all other patients.
             e.     Start seeing new patients.         

12.  Should I see and new patient or make a disposition?  Always err on the side of creating space.  Your PRC scores will increase.

In conclusion put each patient on a pathway to disposition through compartmentalization of all the various tasks.

Wednesday, June 1, 2011

Top Ten Myths about EHR's in the ED

1. Solves endless paper issues
2. Improves work flow
3. Increases provider productivity
4. Generates more income through better documentation
5. Integrates easily with other systems
6.  It's Easier to track patients
7. All Paper and printers will disappear
8. EHRs not specifically designed for the ED, can be used in the ED. They  will provide  adequate physician documentation.
9. Products with a history and track-record are better
10. Tablet-PCs are the only answer.