I’ve alluded to this in a past post: it’s not easy outlining the fatal features that will sink an EHR implementation.
Most EHR vendors prefer to focus on the success stories, the “best practices” of their star performers, and rightly so. “Never repeat a mistake,” my French teacher used to tell me (if “mademoiselle” isn’t pronounced “madame as well,” don’t say it that way, even when asking the question). Don’t stare at the pothole that you’re trying to avoid, unless you want to ride right into it. It’s easier to exhort folks with positive action steps — DO xyz — rather than negative ones — AVOID abc so you can get to xyz.
But with a tip o’ the hat to Battlestar Galactica, we’ve seen it before, and we’ll see it again:
Doctors who are running behind, months into their implementation. When they should hitting their stride.
Kinda takes the fun out of this tech stuff, you know?
Thankfully, there seem to be a finite number of potholes — more like sinkholes, really. If a practice doesn’t avoid these babies, the EHR ride doesn’t just get bumpy, it gets derailed. Journey over.
Sinkhole #1: Chart Abstraction, Revisited
No question, this is the biggest obstacle to timely patient visits right here.
It goes back to that key principle of working to the highest level of licensure. If the physician is playing clerical staff, filling in the medications, allergies, and chronic medical conditions — especially during a visit, when she should be concentrating on clinical matters — that means someone else in the office didn’t. And that’s a waste of the doctor’s time — the costliest, easiest to frustrate time in the entire universe.
Snippets of regained time add up quickly; save 3 minutes on each visit, and you’ll go home an hour early at the end of a 20 patient day. Conversely, spending extra time with each visit will put you hours behind at the half day, especially if you’re taking 5-10 minutes filling in the backstory.
The solution seems so straightforward, because it is: have support staff fill in that chart data, at a non-time crunched part of the day — like the day or the morning before the visit.
- Have staff pull the paper charts on the patients who’ll be coming in later.
- Instruct them to routinely extract the critical information you’ll need for proper context and decision making, and put them in the electronic chart:
- chronic conditions
- medications
- allergies
- a handful of test results like ekg’s, Pap smears, and key labs
- ANYTHING the doctor will need to properly act and think during the visit, like biopsy results the pt is coming back to discuss
Ideally, most of this will have been done as part of your pre-go live scanning and chart abstraction; that’s partly why there’s a 3-6 month lead time for any paper practice before the 1st electronic patient visit. It takes a short amount of time per chart to extract, then insert into the EHR, the few key data points you need to hit the ground running. But with about 2,000 charts…you do the math. The scanning folk gotta eat and sleep, too, you know.
Plus, be honest. Do you floss your teeth every single night? Do you work out every single day? There will be charts that you didn’t insist on abstracting, maybe the cost was getting prohibitive, whatever. It happens, that’s the reality, we’ve all been there.
But, you cannot leave it at that. This work will have to get done eventually, which means it’ll inevitably end up in the physician’s lap. And all work and no play makes Dr. Jack one pissy, “get this EHR out of my face” provider.
Sinkhole #2: Use E-Prescribing, Fa’ Cryin’ Out Loud
The debate still rages on about which is faster: free texting a visit vs. clicking checkboxes. But there are still providers that are dashing off their 1-line scripts on prescription pads.
That’s not so bad, right? Scribbling takes a few seconds, tops, compared to the minutes it would take to prescribe a medication from the EHR for the first time. Surely that’s a bargain gained back, yes?
Buddy, I’ve got front row tickets to the premiere of New Moon I’m dyin’ to sell ya, cheap, if you believe that.
You are multiplying your downstream workload by a factor of FOUR, for every script you hand write as opposed to e-prescribe:
- that little piece of paper still has to be scanned into the chart, or noted with a text entry that YOU have to create (again), unless you’re OK with taking a major treatment action that you fail to document…[chorus: shuddering offstage]
- come refill time, you’ll have to search for that chart entry of what you hand prescribed last time for confirmation
- then you’ll have to rewrite it on that little paper pad again
- and scan or notate that
Not to mention the fact that you’re missing out on the EHR autochecking your prescription against patient allergies, drug interactions, etc.
And let’s not even start about the meaningful use criterion you’re sidestepping (ya gotta demonstrate electronic prescribing), thus negating your eligibility for federal or state healthcare IT reimbursement monies. You didn’t need that $10-14,000 a year, anyway, right?
Pothole #1: Practice, Practice, Practice
The other reason for lead time is to get down and dirty with the system, over and over, again. So you and your EHR are bosom buddies by the time you see your first patient.
This is more of a pothole than a sinkhole, because it mainly applies to those going electronic for the 1st time. But it can derail even experienced EHR users, if they’ve been months on the system but never learned the system adequately. Lost is still lost.
Plain and simple, it takes trained repetition, to generate familiarity with navigating the system; nothing less will do. Depending on your trainers, 3-10 dedicated, supervised sessions, replete with increasingly realistic test patients, will give you the muscle memory you need to reach for the right buttons.
There’s nothing more frustrating than knowing what you want to do, but not knowing how to make the system do it, while you’re 4 patients behind and counting. You learn by doing, just like in med school and residency — learning your EHR is no different. Your go-live day is not the time to figure out where the lab results are, or how to renew meds, or how to order a CT scan.
The number of EHR novices who skip this step is, in a word, appalling.
The number of ongoing, sort of savvy EHR users who teach themselves on an ongoing basis is even larger. The ones who are so frustrated, they don’t have time to learn from trainers who see the physician sticking points every day, and whose job it is to show them solutions. So they keep on learning from…themselves.
Pothole #2: You’re Good, But You’re Not THAT Good
This is exclusively a new-to-EHR doctor issue, but it bears repeating:
You must.
Go live.
With reduced volumes of patients for the first several weeks. Unless you’re a hyper overachiever, in which case, you’re probably not reading this blog, anyway.
Even with proper prep, you’ll still fumble, and be slower than usual. Do yourself and your staff a favor, and build in some wiggle room to account for this. You can always add more patients in to your schedule if you’ve done a stellar prep job, and are shouting, Bring It On! on your pottie breaks.
Telling overbooked patients to go home, you’ll call them back when you’re ready…tends not to go over so well.
Pothole #3: Be A Cad, Take Advantage
Finally, it’s not a bad thing to make the best use of shortcuts the system offers you. It’s more of a sin to not take advantage of features designed to make your life safer, surer, and easier.
Case in point: most systems enable you to customize verbiage to your way of doing things, such as
- physical exam defaults
- boilerplate instructions (like, “Advised to schedule a physical annually for life threatening condition screening”)
- custom sigs and quantities on oft-prescribed meds
- repetitive instructions to staff (like, “See printer, mail lab order to patient”)
You specify the details one time, and henceforth, it only takes a button click to invoke all that unique, specific language.
Yes, it takes time to set these up. And when you’re running behind now, the last thing you want to do is get further behind trying to set up these macros that’ll make your life easier later.
Do you see the loop you’re locking yourself into?
Get Out Of The Loop
If you’re behind, you’re disinclined to take the exact actions that will cure your chronic, recurrent tardiness, so the situation repeats.
You’ve got to break the cycle.
If there’s a logjam or a lateness that doesn’t ever go away, there’s something that’s getting in the way of the fix. The problem is somehow more stable than the solution — not that you prefer a mess, but often it seems like the suggested fix will just make your particular mess bigger, so you clean up just enough to get by.
What you need is mess minus, not status mess.
Identify where things keep piling up. Institute a policy to correct and prevent this. Have it be the rule, not the exception.
And don’t let a little front end work make you hesitate — front end work, also known as an investment, is a sign that you’re on the right corrective track.
