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Teaching To The EMR Template?

Posted on October 7, 2013 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Are teachers of family medicine being forced to teach to EMR templates?  According to one blogger, the answer is a decided “yes” — and it’s probably not a good thing.

In a posting on the blog for the Society of Teachers of Family Medicine, Bill Cayley, Jr., MD. argues: “With the increasing use of electronic medical records (EMRs) and their ever-so-helpful templates, smart sets, and forms for capturing information needed to support billing and guide protocols, I fear we are losing the narrative forest for the well-documented trees.”

Cayley writes  that teachers of family medicine  have a particularly strong tradition of teaching students to write nuanced narratives. “The flow of meaning and story that comes from a patient’s history and give far more insight into what may be going on than one gets from simple documentation,” he notes.

These days, however, EMR documentation pushes  physicians and learners to document positives and negatives rather than the patient’s story, he says. For example:

* Emergency department documentation is growing in length, but conveying less meaningful information. “Documentation of an ER visit that in the past was captured by a one or two page dictated note now comes in an eight or nine page template document that gives no real clue as to what really brought the patient in,” he says.

* Doctors are increasingly responding to the template in office visits, sometimes ordering something because it’s there in the template, rather than listening to the patient’s narrative, he says.

* Far too often, doctors are being forced to re-gather the entire history with the patient themselves, because prior documentation fails to provide the nuance needed to understand what happened during the last visit, Cayley reports.

Even if everything Cayley says is true, it’s worth nothing that templates offer some relief over paper charting duties.  As John Lynn notes, doctors have historically had to go through stacks and stacks of paper to do traditional charting, often bringing home piles of charts just to stay caught up. That sort of backlog has consequences of its own.

But if using an EMR is squeezing meaning out of doctors’ — and future doctors’ — record-making process, that’s a warning sign that shouldn’t be ignored.  Let’s hope vendors find more of a happy medium going forward.

When The EMR Goes Down, Doctors Freak Out

Posted on August 22, 2013 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Earlier this month, health IT superstar John Halamka, MD, MS posted a story talking about how network downtime within a hospital has changed over the past 10 years or so. I thought I’d share some of it with you, because he makes some interesting points about end user perceptions and sensitivities.

First, he tells the tale of a 2002 network core failure of Beth Israel Deaconess Medical Center, where he serves chief information officer. For two days, he reports, the hospital’s users lost access to all applications, including e-mail, lab results, PACS images and order entry, along with all storage. Or as he puts it, “For two days, the hospital of 2002 became the hospital of 1972.”

He then contrasts that failure with a recent one  (July 25 of this year) in which a storage virtualization appliance at BIDMC failed.  Because the hospital was loathe to risk losing data, he and his team chose a slower path to uptime — reindexing the data — which allowed them to avoid data loss. The bottom line was an outage of a few hours.

This outage was a different ballgame entirely, Halamka says. For example:

* In 2002, staff and doctors weren’t incredibly upset, but this time physicians were angry and frantic, with some noting that they couldn’t take care of patients without EMR access.  Here in 2013, end users expect network access to be like electricity, always there short of an act of God. Worse, though downtime simply isn’t acceptable, but procedures for dealing with it aren’t up to that standard yet, he says.

* Doctors are under an incredible set of regulatory burdens, including but not limited to Meaningful U se, health reform, ICD-10 and the Physician Quality Reporting System. They fear they can’t keep up unless IT functions work perfectly, he observes.

* Technology failures of 2013 are tricky and harder to anticipate. As he notes, back in 2002 servers were physical and storage was physical, but today networks are multi-layered and virtualized. While these things may add capability, they also crank up the complexity of diagnosing system failures, Halamka notes.

Halamka says he learned a lesson from the recent failure:

Expectations are higher, tolerance is lower, and clinician stress is overwhelming. No data was lost, no patient harm occurred, and the entire event lasted a few hours, not a few days. However, it will take months of perfection to regain the trust of my stakeholders.

This story does have one ray of sunshine in it — it demonstrates that increasing numbers of doctors depend completely on their EMR, a state devoutly to be wished for by many health IT leaders. But the price of having doctors throw themselves into EMR use is having them riot when they can’t get to the system. Clearly, hospitals are going to have to find some new way of coping with downtime.

Meet the Bloggers Panel Video and Dell Healthcare Think Tank at HIMSS12

Posted on March 9, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Meet the Bloggers Panel at HIMSS12
As many of you know, I was on a Meet the Bloggers panel at HIMSS 2012. I didn’t realize it at the time, but Charles Webster, MD (@EHRworkflow) was sitting on the front row filming us the whole time from a video camera he had attached to his hat #hatcam. I think some good information was shared for those interested in using blogging and/or social media in healthcare.

The moderator of the panel was Brian Ahier and the panelist were Healthcare Scene contributor Jennifer Dennard, Neil Versel from Meaningful Health IT News and Carissa Caramanis O’Brien of Aetna.

Neil was gracious enough to do all the work of embedding each video clips into a Meet the Bloggers at HIMSS post. So, instead, of embedding them all here, head over to his site to enjoy them. I will just embed one video of me talking about healthcare social media below:

One thing became abundantly clear at HIMSS. I love social media and know a little something about it. One of my favorite meetings was with a health IT vendor who wanted to tell me about them and talk about blogging/social media. They started asking questions about blogging/social media first and an hour later we were out of time. That interaction made me wonder if I should put together some one or two day social media training/strategy sessions for vendors. I think one key to social media is authenticity which means I think it’s hard to outsource it.

Dell Healthcare Think Tank
I didn’t participate in the Dell Healthcare Think Tank that happened at HIMSS, but two writers for Healthcare Scene did: Jennifer Dennard and Neil Versel. They posted the whole video for the event and I’ll embed it below. I was able to watch a good portion of it and found a number of the comments quite interesting. I find it really intriguing that Dell would hold an event like this. In many ways, this is how I get the knowledge and insight that I post on this blog. I spend time with many of the people that attended the think tank and we talk about the healthcare IT world.

Meaningful Use Stage 2 Commentary and Resources – Meaningful Use Monday

Posted on March 5, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

For this week’s Meaningful Use Monday, I decided I’d go through the large list of meaningful use stage 2 commentary that’s been put out over the past week. I’ll do my best to link to some of the most interesting commentary, summaries, etc of meaningful use stage 2 and point out some resources that I’ve found useful.

John Halamka on Meaningful Use Stage 2
First up is the blog post by John Halamka about MU stage 2. I really like his recommendation to read pages 156-163 of the MU rule (PDF here). Sure, the rule is 455 pages, but many of those pages are a recap of things we already know or legalese that is required in a government document. Halamka also created a meaningful use stage 2 powerpoint that people can reuse without attribution. Worth looking at if you’re not familiar with MU stage 2 or if you have to make a presentation on it.

Health Affairs on MU Stage 2
Health Affairs has a nice blog post covering meaningful use stage 2. They offer “3 highlights that seem particularly important:”

  1. The bar for meeting use requirements for computerized provider order entry (CPOE), arguably the most difficult but potentially the most important EHR functionality, has been raised: now a majority of the orders that providers write will have to be done electronically.
  2. There is a major move to tie quality reporting to Meaningful Use. We knew this was coming, but CMS has laid out a host of quality measures that may become requirements for reporting through the EHR.
  3. Health Information Exchange moves from the “can do it” to the “did do it” phase. In Stage 1, providers had to show that they were capable of electronically exchanging clinical data. As expected, in Stage 2, providers have to demonstrate that they have done it.

Health Affairs also talks about the timeline for this rule and the feedback that CMS is likely to get on MU stage 2. I’m sure they’re going to get a lot of feedback and while they suggest that the rule will look quite similar to the proposed rule, I expect CMS will make a couple strong changes to the rule. If nothing else to show that they listened (and I think they really do listen).

Stage 2 Meaningful Use by The Advisory Board Company
The Advisory Board Company has a good blog post listing the 10 key takeaways on stage 2 of meaningful use. Below you’ll find the 10 points, but it’s worth visiting the link to read their descriptions as well.
1. Centers for Medicare & Medicaid Services (CMS) affirms a delay for 2011 attesters.
2. Stage 1 requirements will be updated come 2013.
3. Medicaid definitions are loosened; more providers are eligible.
4. While the total number of objectives does not grow, Stage 2 measure complexity increases significantly.
5. Information exchange will be key, but a health information exchange (HIE) will not be necessary.
6. Patients will need to act for providers to succeed.
7. Sharing of health data will force real-time, high-quality data capture.
8. More quality measures; CMS’ long term goals—electronic reporting and alignment with other reporting programs—remain intact.
9. The Office of the National Coordinator’s (ONC) sister rule proposes a more flexible certification process and greater utilization of standards.
10. Payment adjustments begin in 2015.

AMA MU Stage 2
The American Medical News (done by the AMA) has a blog post up which does a good job doing an overall summary of where meaningful use is at today (post MU stage 2). Meaningful Use experts will be bored, but many doctors will appreciate it.

Justin Barnes on Meaningful Use Stage 2
Justin Barnes provides his view on meaningful use stage 2 in this HealthData Magement article. It seems that Justin (and a few other of his colleagues at other EHR vendors) have made DC their second home as they’ve been intimately involved in everything meaningful use. I found his prediction that the meaningful use stage 2 “thresholds and percentages will remain largely in place come the Final Rule targeted for August, and should not be decreased via the broader public comment phase next underway like we saw with Stage 1.” Plus, he adds that the 10 percent of patients accessing their health information online will be a widely discussed topic. Many don’t feel that a physician’s EHR incentive shouldn’t be tied to patients’ actions. Add this to the electronic exchange of care summaries for more than 10 percent of patients and the healthcare data is slowly starting flow.

Meaningful Use Stage 2 and Release of Information
Steve Emery from HealthPort has a guest post on HIT Consultant that talks about how meaningful use stage 2 affects ROI. This paragraph summarizes the changes really well:

The bottom line for providers is that Stage 2 MU changes with regards to these specific criteria will drive organizations to implement a patient portal or personal health record application; and connect their EHR systems to these systems. Through these efforts it is expected that patient requests to the HIM department for medical records will decrease; as patients will be able to obtain records themselves, online and at any time.

e-Patients and Meaningful Use Stage 2
e-Patient Dave got together with Adrian Gropper MD, to put together a post on meaningful use stage 2 from an e-Patient perspective. This line sums up Adrian Gropper MD’s perspective, “My preliminary conclusion is that Stage 2 is a huge leap toward coordinated, patient-centered care and makes unprecedented efforts toward patient engagement.”

Meaningful Use Stage 2 Standards
Those standards geeks out there will love Keith Boone’s initial review and crosswalks from this rule to the Incentives rule here.

Shahid Shah on Meaningful Use Stage 2
I like Shahid Shah’s (the Healthcare IT Guy) overview and impressions as well. He’s always great at giving a high level view of what’s happening in healthcare IT.

Are there any other meaningful use stage 2 resources out there that you’ve found particularly useful or interesting?

Medicare EHR Incentive Resource and Healthcare CIO on 2011

Posted on January 9, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

A couple quick tweets to welcome your new week. Both tweets stand on their own and link to some good reads for those interested in the topics. The second one is particularly good since it’s John Halamka’s 2011 wrap up across all the various parts of John Halamka’s life. Let me know what you think of both reads.

EMR As Electronic Version of Chart…Or is it EHR?

Posted on October 9, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We’re back once again with our weekend roundup of a few interesting EMR and healthcare IT related tweets. Seems like the #hcsm chat was enjoying tweeting about some of the challenges of EMR and EHR:

@RyanMadanickMD
Ryan Madanick, MD
EMR=elec versn of chart RT @MrPug94: T1 #hcsm There really isn’t a true provider-patient collaboration platform. #EMR is simply a database

I agree with the assertion. Although, the reason an EMR is just a database and not a true provider-patient collaboration platform is because there’s no exchange of data. That’s what’s missing most from today’s EMR software.

Then, I also saw this related tweet about EHR:

@JackWestMD
H. Jack West, MD
Also, w/#EMR, it has never been easier to produce so much boilerplated documentation that says so little. #hcsm

I know where this comment comes from, but as I said in previous posts. I think we’re ready to see a revolution in clinical documentation that kicks against the boiler plate documentation that’s been so dominate in legacy EHR software.

Plus, is anyone else still kind of annoyed that we’re still debating whether to use EMR or EHR?

@EHRgeek
Helen Phung
@ehrwatch @nestorarellano @WittRZ Used interchangeably. #EHR refers more often to a physician/patient facing record while #EMR is for docs.

Personally, I have one thing to say about the EMR or EHR debate: Who cares? Once you can use them interchangeably to communicate the same thing, it really doesn’t matter. I tell you now that it really doesn’t matter.

Interview with Meaningful Use Physician #23

Posted on April 19, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Yesterday morning, River Falls Medical Clinic (RFMC) of River Falls, Wisconsin, attested for Meaningful Use at 7:30 a.m. CT. The clinic was one of the very first – in fact, #23 to attest to meaningful use under the Medicare program. The following is an email interview I did with Dr. Tashjian about RFMC’s experience in the meaningful use attestation process.

Christopher H. Tashjian, MD is the president of River Falls, Ellsworth & Spring Valley Medical Clinics in Wisconsin. The three clinics provide primary care services as well as specialty consults.

How long have you been using EMR? Which EMR do you use?
River Falls Medical Clinic, RFMC, implemented Cerner’s Ambulatory EHR in March of 2010 after several years of working with Cerner’s PWPM solution.

Did you have to upgrade your EMR to meet the certified EHR and meaningful use requirements?
From day one of EHR implementation, our staff has made it a priority to utilize our EHR solution to its full extent to benefit the care we deliver to our patients and to enhance our workflow. From the time Meaningful Use was announced, our staff was quick to realize that the proposed criteria would help us to better utilize our EHR and to enhance the care and delivery of that care our patients. We made it a goal to not simply attest for Meaningful Use for the monetary benefits that the stimulus dollars provided, but to more importantly enhance patient care. Therefore, we did not upgrade our EHR to solely meet the certified EHR/Meaningful Use requirements. We did add several pieces into our daily routines including Cerner’s departure summary and patient education –even though this piece isn’t required this year, we know that it will be in stage 2 and beyond. We also continued to improve our eprescribing procedure. We will also be upgrading to include Cerner’s IQHealth® solution to provide a patient portal that enables patients to review their own information and interact with us within a secure platform.

How much did it cost for you to do that?
There is a cost to move to an electronic record from paper – RFMC’s physicians feel it is vital to recruit today’s top medical students/residents. We felt if we did not have an EHR, we were at a serious disadvantage. More than 70% of the physicians in our area have gone electronic– we had to stay up-to-date. Patients in our area want to see a physician who has embraced technology and made the commitment to enhance patient care and safety; they want a physician who is moving forward with technology, not one who is still using paper when a better option is available. There is a cost associated with being a provider of choice and RFMC, like any other physician office, wants to attract new residents (physicians) and new patients. Providing better care is one way to do this. There is no way we could stay competitive in the marketing place if we did not choose to go electronic. The cost of not doing so was too high.

Why was it important to you/your office to be one of the first physicians in the nation to attest?
We wanted to make sure we were doing it right – we looked at the Meaningful Use requirements and said, “These things all appear to provide measurably better care.” Our physician’s felt that meeting Meaningful Use requirements would point our focus in the right direction. Most importantly, we wanted to follow the steps to enhance care. There is value in being one of the first physicians to attest and in being able to tell our community that RFMC is up and running at the first opportunity. This is of significant value to us. Additionally, our physicians literally put their own dollars into the HER; we made a personal investment in this. Many private groups owned by physicians have followed the same suit. This is not a situation where we just said, “Okay, we can rearrange some dollars.” If we don’t succeed – we don’t take our money home. It’s very personal to us as individuals and meaningful because we practice medicine to help our patients. Additionally, we wanted to be able to assist our fellow physicians in the process. By being one of the first physicians in the nation to attest, I can provide feedback and suggestions to assist others in the field.

How many hours of extra effort do you estimate it took for you and your staff to meet the meaningful use criteria?
We were committed to meeting Meaningful Use requirements already, so it’s difficult to say exactly how many hours we put into this initiative specifically. There were many hours spent making sure we met the requirements. We felt the requirements were so valuable and worthwhile that we began working on them day one because we felt they would enable us to deliver better care for our patients. Instituting an EHR required significant effort to change the way we document and the way we take care of our patients, but we saw this as part of the natural cost of doing business and we chose to do it in real time rather than seeing fewer patients. Our staff simply worked more hours – longer hours –so we did not interrupt the care to our patients. Within 6 weeks we were back up and running at full speed – this really is a fairly rapid adoption.

What were some of the changes you had to make to your practice style or documentation methods to meet meaningful use?
We aim to have all notes completed the same day. For us, this was a huge transition from the dictation world. Our team had to learn to document electronically and have things done by the time the patient left the room. This is vital for our patients incase they find themselves visiting the ER that night or seeing another physician that day. In these cases – the information on their visit with our physicians is complete and available. We also completely transitioned from writing prescriptions and went all eprescribe.

There were several changes in the way we practice. For example, now, every visit ends with the patient summary, which I never did before. Now, I sit down with the patient and whoever is with them to discuss, “Here is what we did, here are the tests we conducted today, the labs we completed and prescriptions written.” I provide a full, comprehensive overview of their visit. Incorporating the patient summary into the exam has enhanced my relationship w/my patients and they feel more confident walking out the door. Before, visits ended with a physician writing a prescription and saying goodbye.

We’ve also decided to put printers in every room to provide the after visit summary to our patients. We want everyone to receive their after visit summary and to get the appropriate patient education. We’ve gone to two-sided printing for all documents, so we aren’t printing anymore than what is absolutely essential for each situation. This is helpful for our elderly patients who are on multiple medications, which can get confusing. It’s easier to keep track of everything if it’s written down. We’ve also received feedback that this is valuable for their caregivers who may not have been in the exam room with them. On the other end of the spectrum, this is incredibly beneficial to parents of children, particularly newborns. Parents want to track progress and they want to be able to easily recall information. As we adopt Cerner’s IQHealth®, we anticipate moving the majority of this information into the patient portal for easy accessibility and storage in one central location. We also regularly utilize the immunization registry, which we did not engage with previously.

What steps did you take to ensure you were ready to attest?
To ensure we were ready to attest, we used the reporting capabilities within Cerner’s solution to extract the appropriate data. We used weekly reports to note where each physician was in regards to meeting the requirements for attestation. We also enlisted the support of WHITEC, The Wisconsin Health Information Technology Extension Center, to make sure we covered every base.

Were there any surprises in the meaningful use attestation process?
I was overall impressed that the process was put together so meticulously. There were multiple forms that needed to be filled out as we went through the process, and our staff truly did their due diligence prior to “pushing the button” to ensure we were ready. Thanks to the staff’s preparation, we were prepared when the numbers were requested. It was very easy for us.

Who helped you through the process (your vendor, a consultant, your REC, etc)?
Cerner played a large part in our success. Early on, we began working with Karen Berg, a Cerner Ambulatory director, who came to our clinic to meet with our quality physicians and walk us through the process of getting signed up for Meaningful Use. Berg worked through our questions to help physicians get ready to attest. She highlighted the need for us to prepare for Meaningful Use and beyond and laid out foundational steps for us to focus on patient care beyond Meaningful Use. We have been pleasantly surprised by the wealth of resources available through uCern, a collaborative website for Cerner clients, and we use them regularly. Additionally, our office manager receives regular emails from a group of people at Cerner who are dedicated to help their clients attest and prepare for certification. On our behalf, Cerner also works hand-in-hand with WHITEC, a health information technology extension group that our peer review organization put us in touch with. WHITEC has been very helpful for directing us through the Centers for Medicare and Medicaid Services website and doing research around questions that arise.

What benefits are your patients seeing from you showing meaningful use of an EHR?
Overall, our patients are receiving better quality of care as a result. They’re receiving patient education as well as after visit summaries and their information is tracked for accuracy. Their immunizations, which are one of the most complicated things for parents of minors to track, are recorded in the immunization registry and interfaced with the Wisconsin Immunization Registry. We’ve eliminated errors through eprescribing, there are simply no more errors due to handwriting legibility. They don’t have to worry about losing a prescription, because we send it directly to their pharmacy electronically. Eprescribing also conducts side effect checking and keeps record of the time and date a script is written and sent. Interoperability is a huge benefit for our patients – there is now no need to transfer things to other physicians in our 5 sites, which saves the physician and patient time.

What efforts are you taking to progress towards meeting meaningful use stage 2 and beyond?
RFMC is excited to move forward towards Stage 2 and beyond. We’re already working on next year’s goals; that is, giving diagnosis related patient education to my patients.” We have implemented Patient Education within our practice. We’re moving ahead to continue to deliver the best to our patients.

What do you say to your fellow doctors who are concerned about implementing an EHR in their practice?
I have never met a physician (who has moved to electronic records) say they would like to go back to paper. True, it requires a concerted effort to move to the EHR but the gains in patient care are worth it.

What do you know now about attesting for meaningful use that you wish you knew prior to attesting?
Be organized, choose the right vendor and all will go smoothly. If you actively work to do what is in the best interest of the patient, meaningful use will naturally follow.

What can you share with other physicians who are getting ready to attest in the next weeks and months?
There is very little way to prepare other than to prepare your attitude. Meaningful Use is the way the industry is going and we’re on board with a focus on our abilities to better our care – it’s a job standard to move in this direction. So, jump on board.