Thursday, September 24, 2015

Technical Support for EHRs

Technical Support for EHRs

Those in the healthcare EHR industry know full well that a vast majority of support calls stem from issues potentially solved locally, with little or no technical know-how needed.  That is why most all tech companies, medical or not, provide FAQ support information, commonly online or on paper, that can be used to quickly consider and resolve issues.  It’s like the manual in a new car when you need to figure out a “how-to” but want to keep the vehicle running.  And few in healthcare have the time for their vehicles (EHRs) to stop running or slow down. At times though, more than the manual is needed, either for more in-depth information, or for hand-holding through some simple problem that nevertheless induces anxiety. Still, support teams commonly consist of rotating responsibility by the program developers, they rarely have time (or patience) for hand-holding.

For example, most facilities use printers, either for patient-care instructions, prescriptions, or for other printed care documents.  And yet, printers are often a big stumbling block for end users, who may be technically unskilled, new to the system, or rotational members of a staff that services multiple care facilities. Problems with these devices, however, are usually rather easily corrected.  Nevertheless, an EHR system that is functionally brought to its knees because the printer went out, can induce panic in the facility staff.

And then there are software, hardware, or internet-based technical issues that do crop up.  Who of us has not gone partially bald waiting hours online for Microsoft or Apple to provide an English speaking helper to resolve a problem that is making smoke pour from our ears, and impairing our lives.  It happens with all devices, from “smart” phones to ipads to laptops.  Yet, in the hospital or clinic environment, delay of this sort is not only frustrating, but dangerous.

How does a tech-support crew best solve such matters?  For one, be sure that your vendor has provided you with key items of access. They are:

1.    An FAQ-problem list of the most commonly encountered glitches, and how to solve them. This list should have easily located, step-by-step instructions, understandable by even the most novice clinician doing a new shift at the facility.  It should include an instruction to shut down (all devices) and restart as a next-to-last-ditch effort, and then to move to #2 if this fails. The FAQ sheet should be placed in a secure, known, location at all sites, and available to all users of the system.
2.    Phone contact information:  this should be clearly stated on the FAQ sheet. It may be helpful to distinguish more than one number, one for emergencies that have not been resolved locally, and another for issues that can wait until the next business day for resolution. 
3.    Support management by the EHR support service should include an initial re-routing message of the sort one hears from hospitals and physician offices:  if this is an emergency, hang up and dial 911.”
In the case of technical emergencies, it might say:  “if your system is down, press 1.”
Or it might further define a true EHR emergency and say, perhaps “if you have a technical issue with your system, and it is now impairing the care of patients, press 1.”
When the issue is not urgent, further information might route the caller to voicemail to leave a message for the staff when they are available to respond.
4.    Follow-up and analysis by the vendor:  all EHR vendors should be interested in learning how requests for help are handled and resolved  A mechanism for doing so, either by email, website contact, or direct call, should be set up. That way, all involved parties can continue to improve their relationship and their abilities in keeping every installation of the system up and running.

Be sure that you and your vendor discuss elements of support, and how it is to be managed, so that you can work together to keep your facility seeing patients as efficiently as possible.

Tuesday, September 15, 2015



Guest Blog (DRK) with Oversight (RB)

As an emergency medicine resident in the (very) late 1970’s I serendipitously happened to create one of the earliest renditions of an ED tracking board. Resources being scant, I went to the local office supply, to buy a very large erasable white board, which took up an entire wall.  On it were placed strips of colored tape in vertical columns for patient names, chief-complaint, stage of care, pending issues, and anticipated disposition; each room or care-space in the department had its own horizontal row.

Why in the world did I do this? Well, it is of note that after a few years, the hospital became the urban flagship for the University of Florida EM program. I was an attending. Many would wander into the area to see this “device,” and my explanation for its presence was as an attempt to make evident to all what was going on in terms of compartmentalization and strategizing. Before then, in my experience, that cognitive process remained rather non-communal, as it was usually kept within the heads of the docs and head nurses, spoken by mouth, and maybe visible, if at all, only via clipboard rack.  This new board seemed a step forward, in that other doctors, nurses, and ancillary staff, could all see what was going on, often at a single glance.*  Communication as well as prioritization (compartmentalization) was enhanced.

Now those of you who have grown up in EM and UC medicine since may well find it hard to visualize a world without tracking boards.  You may also find it hard to imagine a world without cell phones.  But in each of those instances, the world was, indeed, long (long) without these.

Since those earlier times, when working on developing one of the first EMR programs for the ED, placing tracking board functions within an electronic system became a goal.  Decades later, even with that functionality, though, we are still, for the most part struggling.  Why? Principally because efficient EM practice requires individual, personal, compartmentalization, in addition to whatever may be going on from a global, departmental view.


         The Merriam-Webster Dictionary defines the verb compartmentalization as three kinds of actions:
: to separate (something) into sections or categories
: to separate (two or more things) from each other
: to put (something) in a place that is separate from other things.
         At its best, and even at its not-so-best, compartmentalization allows one to deal with large quantities of input at the same time, in a variety of situations, and without getting confused, agitated, error-prone, or stressed.

         A classic example is the single provider Emergency Department or Urgent Care with 8 or more simultaneous patient encounters. The stressors on the situation are
1.   Time
2.   Patient satisfaction
3.   Making the proper diagnosis and treatment plan
4.   Interruptions
5.   Interactions: staff, family, phone calls, new information.
6.   Interruptions
7.   External forces demanding unreasonably rapid patient flow.
8.   Interruptions
9.   Finally, the hardest one: following up on each individual patient to ensure that 1-8 have been handled thoughtfully and reasonably.
10. And then: finishing the endless documentation formally known as paperwork.

A mental compartmentalization technique can be used to divide up the patients in a prioritized manner that limits potential for confusion. After each patient is seen (by you), they are put in virtual mental schematic of the department, noting their location, their problem, the key bits of information needed to make the final disposition of this patient, and the typical time frame needed to make a disposition for this complaint. Think tracking board, but written within your own mind.

An example would be a patient with RLQ pain in room 2. Your disposition will perhaps be based on the results of the CT scan for appendicitis and you expect completion in about 2-3 hours. At the same time, you might have a patient with an Acute MI in room 1. Your anticipated disposition here, is arranging for catheterization and initiating a treatment protocol. Time frame should be 30 minutes to hour. Now the patient in room 8 has bronchitis. Disposition in real time with prescriptions and follow up, might be completed in   30 minutes to hour.

All this is inescapably overlaid on a fact sometimes noted, but rarely voiced: the best of the “older” ED docs would have diagnosed with ADHD as children. Had the current version of political/diagnostic correctness been in place in prior generations; likely they would have been medicated, and real talents pharmaceutically precluded.  That is, an ADHD-like cognitive mind is a benefit in the ED. Woe to the doc who has to complete one thing before going on to another (we all know them). Attention has to shift, and rapidly, but nevertheless, to be effective, a supervening mechanism to focus attention is needed.  Compartmentalization, mental compartmentalization, is indeed such a mechanism.

If you can compartmentalize your thoughts, and prioritize your actions, you can deal with the heart attack, check for the CT on the tracking board, and discharge the low acuity patient, almost simultaneously. The result is a well compartmentalized, well prioritized, tiered tracking board; the highest tier is (mental), within you; the next tier is external (physical) a displayed tracking board. The one (mental) sits inside the other (displayed), but only the displayed version is visible. Your mental board shows the rows and columns for you to easily access.  The ancient Greeks used to use this type of mnemonic scheme to facilitate memory of huge amounts of data. They would visualize a large building with many (many) rooms, cubicles, spaces, and into each would mentally place any item they wished to remember.  To retrieve, they “went” where they knew it was.
 Using this technique can help you to function efficiently, multitask, and move patients through the department.  Notice it requires a bit of balance, and assumes some conditions that may or may not be present in your facility at all times. For example if you have three MIs and an incoming rescue unit, your compartmentalization/prioritization is going to have to achieve a different level than if you have one rash to see. But it can be very helpful, even under significant stress, to be maintaining your own internal tracking board. In fact, even if you hav three MI’s going on, you can probably also handle a rash.

All this does take practice, and a key to making it work is pre-thinking the steps needed to make disposition on the case, as early in the encounter as possible (like after the first 5 words). A partner of ours (name unmentioned) was known for making dispostions at the time the first EMS call came in. If you can train yourself to think [encounter-->disposition], you will be 10 steps ahead of the game.  Even if there are three active MI’s, you will be thinking about which ones are going when to the cath lab, which are being transferred (perhaps), and also what to do with the rash. Such direct planning is rarely, if ever, written on actual tracking boards. Developing, practicing, and “seeing” your own internal tracking board and using the material/actual tracking board as a real-time assistant will significantly enhance your ability to process patients.

XpressTechnologies Electonic Health Record with charting, tracking board, prescripton writer, and follow-up instructions has been time-tested to dramatically improve efficiency.
 *For those of who like to research such things from an academic/theoretical viewpoint, consider the article by Berg Computer Supported Cooperative Work 8: 373–401, 1999 Kluwer Academic Publishers. Accumulating and Coordinating: Occasions for Information Technologies in Medical Work. This pivotal work is not-uncommonly referenced by another seminal thinker Bob Wears (e.g. The Chart is Dead—Long Live the Chart Annals of Emergency Medicine Volume 52 No 4- October 2008 p. 390….and many more).

Thursday, September 3, 2015

Reimagining The Electronic Health Record

           The blog by Ken Terry "What Will EHRs Look Like in 2020?" is quite thought provoking 

It corresponds to our previous item "2020 Hindsight" as both identify the need for systematic change to make the Electronic Health Record  a welcome addition to anyone’s practice.

         We are writing this blog as an interactive piece, with the intent of stimulating discussion and dialogue. We will make some suggestions below; they are by no means complete. We'll then encourage others (you) to give their (your) opinions. Here are some key points that we think an EHR of the future, and the healthcare IT environment in which it lives, should address and push for:
1. A NATIONAL DATABASE: Creation of a national healthcare database with the intent of including every individual, with records presented via a standardized format.
a.Yes, this is a bit far off, and there are obstacles. However, we feel this goal is so key that planning and development now should take into account the needed sub-steps along the way, for its achievement. Otherwise, we will continue to be untangling spaghetti for eons.
b. Such a central database would streamline access to health information for every patient interacting with any Electronic Health Record in the country.  While the term "interoperability" is frequently tossed around, the fundamental point of interoperability is ability to easily share information. Central storage is not really necessary, but centralized access is.
b. Direct incentive-type funding.  Meaningful use was an understandable first effort. But putting huge incentives into time and work consuming data collection queries, has made providers suffer, with little benefit. When a national database is available, information can be more easily examined to determine how EHRs are being used in identifiably meaningful ways. 
c. Movement in this direction would be like putting the money in the bank.  As it became established, it would be a fundamental and available resource.
2. STANDARDIZATION OF CPOE: Creation of a standardized national Computerized Order Entry (CPOE) system with its user interface replicated at every care-site care would generate huge improvements in safety and efficiency. Modifiable order sets for key presentations could be built and maintained by specialty/sub- specialty authorities, and adjusted to meet local needs. 
a.  This would represent a significant advance, allowing providers of all stripes to interact with local systems when directing care, without endless learning curves.
b. Optimally, the entire staff should be able to use the system rather than the highest paid providers being the data input clerks. Various levels of authority would allow hierarchical verification and acknowledgement of orders, promote safety, discussion of clinical course, and appropriate supervision of ordering.
c. One would expect that developed orders would be care-setting specific (modular) and provide the most common orders in easy array of choices.
d. Order interaction with the pharmacy should also be care-setting specific i.e Emergency Department, operating room etc. Moreover, prescriptions/e-prescribing should be care-setting, care-track, and provider specific.
e. Simplification could be globally anticipated. For example calculators (such as pediatric dosing, and other weight/age based therapies) could be straight-forward and easy to use (see the local ATM)

3. INTELLIGENT CLINICAL DECISION SUPPORT: It is time for research to progress in the realm of clinical decision support. Artificial Intelligence is making its way into the world (think Siri), and medicine should not be behind in this exploration. 
a.  A real potential benefit of an EHR in clinical care is in the promise of AI. Right now, most of the research needed on any one case is still on our shoulders. Who of us does not do a google search or explore a reliable source (like "Up-to-Date") on a frequent basis to support of clinical decisions.  The butler (Siri's colleague) can help do that for us. 
b. A good system ought to be aware of your needs, even before you are conscious of them.  Should not a differential diagnosis be automatically generated from the information within your CC, HPI?  If the computer recognizes certain symptom complexes, the provider is supplied can be given easy access to information, treatment protocols, policy recommendations, and appropriate reminders to consider key diagnostic options.
c. Also included should be medication alerts that indicate potential severity of pharmaceutical choice and dose.
4.   SIMPLIFICATION: in the design, construction, and implementation of the actual EHR. For example:
a. Make nursing notes, provider notes, labs, x-ray reports, etc. accessible without having to go to multiple screens to find them.  This is technology available now.  Tabs, mouse-overs, and other tools should be fully implemented in the EHR space. (Google News is a good example of a summary presentation that includes all potentially important items)
b. Artificial intelligence/decision support suggestions should appear in a way that supports the provider’s ability to look over and collate all the data.
c. Another example exists in the sometimes disparate modules that comprise an enterprise EHR.  Direct interaction between the EHR and the tracking board is essential to assist providers and caregivers in controlling a flood of information and prioritizing decision making. Why put information in twice, three times, or more?
These are just a few suggestions. Please add your own below. Let's help make the record a real-time clinical assistant instead of just a medical-legal document and a billing tool for reimbursement.