Who You Gonna Call???

In the article CA hospital experiences EHR failure, the emergency department closed down after its Electronic Health Record system failed aka went down.  The providers were unable to access old records, verify physician orders, access la and radiology reports, and properly dispense medications.

This hospital either didn't have a back-up plan that was well known to the staff and/or the personnel were unable to create a stop gap solution.

 

The real solution is to have a sophisticated back-up plan that is easily followed and everyone is aware of.  In the old days, paper was used quite successfully to complete all transactions. 

It should be expected that an EHR system will have periods of down-time due to maintenance or the dreaded crash!

Polypharmacy Is Not Just For Getting "High"!

In the article Medication Issues in Urgent Care, Dr. Bhogal points out the complexity of treating elderly patients with multiple medical problems.  More than 40% of senior citizens take more than 5 prescribed medications per month.  20% of Medicare patients have 5 or more chronic conditions and 50% of these take 5+ medications per month.

This subject is so complex elucidating drug-drug interactions, allergic reactions, inappropriate medications, dose-related adverse drug events, and prescribing cascaded- adding a new medication to remedy the side effects f already prescribed medications. 

 

Polypharmacy is a term used to describe a patient who is prescribed four or more medications and generally are adults over the age of 65.  We have often suggested that we no longer list all the medications, but weight them.  Many patient have 3 different version of attain they are taking.  Their medication list does not always include over-the-counter medications, herbals, vitamins, and supplements.

 

The average practitioner cannot keep up with all the medications and interactions without the help of a warning system.  Probably the most common cause of weakness and dizziness after ruling out life-threatening conditions is medication related.

 

The practitioner must have access to the appropriate information.  However, when one looks up any medication, the side effects go on for 3 pages and do not necessarily place the potential problems in any hierarchal order.

 

This is one place where the electronic health record with their CPOE and ePrescribing modules can potentially give real-time information to the providers.  The ability to pull medication history, check drug-drug and drug-allergy interactions for a patient in real-time allows the providers to reconsidered their treatment plan.  Medication reconciliation is a major time consumer, but ultimately needs to be done by the primary care physician or surrogates.  Urgent cares are now providing more and more primary care, so they will need to adapt to this new paradigm.  Everyone always worried about allergies, but drug-drug and drug-allergy interactions, dose-related side effects and cascading prescriptions has added a new complexity. 

 

 



 



Who Owns the Data???

The battle for interoperability and easy data transfer is just beginning.  The author of Electronic Health Record vendors Take Patient Data Hostage: What Should We Do? suggests that the electronic records incentive program aka meaningful use has bee fairly successful in getting providers t adopt and EHR system.  However, the interoperability and goal of instant data sharing has not gained much traction.

The majority of EHR product vendors are unwilling to work with competitors through HL7 interfaces to solve this problem.  They charge exorbitant rates for data transfer and HL7 interfaces.

This leaves the provider with the question, "Who owns the date?".  A cynical view would say that in hierarchical order is the NSA, CMS, Google/Apple, Vendors and lastly the provider and/or patient.  In the article, several solutions are offered such as doing nothing- allow market forces to fix the problem, forcing cooperation through more legislative or administrative mandates, or continue to pay through the meaningful use program for interoperability.

When a provider wants to switch EHR vendors, the issue of data transfer comes up last.  The cost of this process inhibits the practices' desire to try something new and possibly an improvement.  It greatly discourages boutique products that are specifically designed for specific lines of business since the price to interface with balky enterprise systems is cost prohibitive for a small practice.

It will be interesting how the quest for free data belonging to the patient is resolved!

Should There Be a Continuous Medical Education Mandate for Computerized Order Entry and Meaningful Use?

MA Physicians Must Show EHR Proficiency; the State of Massachusetts now has licensure requirements the include proficiency in the user of the Electronic Health Record (EHR).  These include understanding computerized order entry (CPOE), meaningful use, and the core EHR. 

In Florida, there are core continuous medical education (CME) requirements: HIV, medical errors (risk management) and domestic violence.  Clearly, every time a new "hot problem" arises, a new CME requirement is generated.  Next will be Ebola and vaccinations (measles, flu,?).

It is not necessarily bad to make sure that everyone is up to speed on certain topics, but what topics should be selected?  A case can be made for multiple topics both general and specialty specific.

The issue with adding the EHR under the general CME umbrella is a lack of industry standards.  Knowing how to use an EHR at a specific location does not necessarily translate into competence with other EHR applications.  Workflow is characteristically site-specific, so users ma approach the software quite differently.  You would not deal with an automated CPOE interface the same at a 120,000 visit ED as you would at a 14,000 visit ED. CPOE varies from vendor to vendor as well as the workflow for using CPOE from site to site.

 It is often essential to understand the result of a right click on the mouse  on any system. How about when going from system to system?  Will you get rodent dyslexia?  Maybe!?!  For more on the right click, read my prior blog on the Right Click Dilemma!  It is noteworthy that recruitment ads for locum tenens already include the type of system in place at the practice or hospital seeking physicians.

The second piece of the puzzle is understanding meaningful use.  Understanding meaningful use?  Seriously!?!  Remember that MU is the government's attempt to promote adoption of EHRs.  It does not, and should not, directly affect patient care.  Attention to it by practices and hospitals is ordinarily to make sure they get their share of the incentive money.  Physicians are being told, "please check these boxes, so we can be paid", but unless a physician is seeking to become an informatics subspecialist, does he or she really need to know what MU is about?

The ultimate solution is establishing national standards for the operation of any EHR, including CPOE as well as patient databases.  If every system used the same fundamental database and CPOE, the provider can figure out the various approaches used by vendors.  Remember, the Massachusetts medical society backed this issue.  HL7 has been working on it for years, and has many tools to enable EHR standardization.  Why not adopt realistic standards?  That would certainly be a meaningful, and useful thing to do.