Paper Towns, Part 2
Tags: Health Informatics, Ehr, Study, Healthcare, Mshi

Paper Towns, Part 2

Picking up from our paper trail…

Now that we know how Hospital H’s outpatient medical records work; we turn the page to issues and challenges they may have to face when they convert to an EMR. (Likely soon?) Chapter 3 of the EHR Manual gives us these challenges below:

What about “to consider”, not yet certain with the diagnoses?

A trainee/resident may possibly write in the OPD chart: “Systemic Lupus Erythematosus, in acute flare….” with so much detail, because it’s part of the training. Some more senior physicians may write “SLE” alone or “Lupus”, and the rest of the information in the <S/> and <O/> portion of the chart. It’s not wrong. What about MCTD, that has some SLE features. Does the doctor write “MCTD” alone, or “Mixed Connective Tissue Disease?”, or do you include the “SLE” in the <A/> portion or not? What about not yet diagnosed but suspicously autoimmune cases. What would we write in the computer? “T/c”? “Possible”? “to R/O”?

If Lola Techie can do it in 2009, you can do it to!

There are five consultants in my department who uses a form of EMR. Each five have different versions. One of them made the set up themselves, relying on simple word processors and a LAN. But not everyone can make their own set up. When I created a Google Drive account for the department and introduced basic excel formulas, I discovered some of my colleagues use excel to, er, manually count, like, per cell. I realized I didn’t determine the level of computer know-how of everyone.

In conversations with an EMR provider, one of the tips some of their clients use to transfer old paper charts was to photograph them like laboratory results. Some physicians will be uncomfortable with this, and they will opt to create detailed summaries during initial transfer of information. Also, photographed results aren’t plottable, hence you have to type it out as well.

Looking back at the failed EMR of the IM Dept, I called up a former end user who was there right about the time it was scrapped. Some of the issues were:

Lack of space. Say the outpatient department would have 15 tables. 10 are for general medicine, plus laptops. There are limited power outlets. There are other subspecialties who also hold clinic hours. Plus the patient. Plus patient’s companion. Plus medical students. Plus consultant-on-deck. Did I mention there is an OPD nurse/s too? (at that time) Poor network reception. The laptops were supposed to connect to a printer, if you could even print at all. And if there was ink. On the program itself, some bugs were never addressed. Glitches on saving, loading, data entry were not fixed. Now that I think about it, I never saw the user interface if they ever actually used it. Funding. Apparently it came to a point when it was: “Bring your own paper” for printing. Once the project was scrapped, all 10 (new!) laptops were stored in a locker. I’m not sure what they did with it afterwards, though. Integration/Implementation. Since other subspecialties like us in Rheum were not in any plans for an EMR, general medicine still printed their output to be inserted in the patient’s folder. Workflow issues. Tempers would apparently flare as to who would charge the laptop, who borrows the key to the locker, who returns the laptop, who takes care of the laptop, etc. Ward responsibilities may extend unexpectedly and the resident could be late, faster to just write than set up the table and connections. Even patients weren’t informed of the system change hence: Hindi naman ako chineck-up ni Doc eh, nagko-computer lang siya.

For Rheumatology; there used to be only one fellow per batch. Now there are two. Four laptops cannot be provided for this purpose alone. Clinic hours are only twice a week, and as mentioned from the general medicine problems, the social service clinic is shared with other subspecialties. Same for the infusion center.

In private OPD clinics; costs such as printer; internet and subscription fee of the EMR provider needs to be considered. When I started my clinic, I didn’t have that kind of budget. I made a simple word processor type for a while.

A patient who consults in Hospital H; may or may not probably be seen in Hospital Y. If you, theoretically, combine the encounter, that patient will be counted as 2. Reasons for this may vary; maybe the consultant changed the schedule for consult. (Or is out of the country). Maybe the laboratories are cheaper in the other hospital.

Same concerns as #1. Who monitors what? If this is my style of writing and recording information, why would it be wrong? It fits my schedule and workflow, what makes what I enter, of less quality?

As mentioned from last blog post; for trainees, its usually ends up a combination of styles you learn from training.

ICD-10 is now in it’s version 2020. The protean manifestations of the disease are too great to use ICD-10 for a general identification of diseases.

Some physicians also may use a different ICD-10 source without knowing that there is an update.

In relation to Resistance for this item; training staff to achieve the required skills is subject to 1) funding, 2) actual interest. Besides the medical doctors and nurses, don’t forget that if you use an EMR, you have to train your secretary too. And provide a hardware for them to use.

Generally, for technology, costs choices are difficult. For example; I was not too interested in get training for msk ultrasound before; because at that time I knew I was going back to a hospital that didn’t have one. I didn’t have a budget for an EMR, why would I need to learn an equipment I could never afford.

The last issue /challenge I think is the most important. There must be a collaboration between physician clinicians, hospital administrators and HIS experts. Funding and Training is the most important part for both.

When I ask what elements the department wants in a census, they list off so many things. But when I ask them why, the answer is always: “For convenience” or “That’s how it’s always been done”. We need clear objectives, a purpose for shifting to electronic, not because it’s shiny and new, but because we want to improve healthcare delivery.

I found the interview of the past users of the failed EMR set up of Medicine, very interesting. Because all these issues came from one very big wrong move: their priority was technology.

There was no consultation on opinions of the end users. There was no consensus among attending physicians & subspecialty services. There was no evaluation on how this could affect current workflow of the trainees. No governance. A few leaders just thought it was a great idea. It was. But there was no method to the greatness.

I heard through the grapevine that Hospital H has plans for a hospital-wide EMR after scrapping an ER-based one. I hope this time they will have a better planning / strategic committee.

Otherwise, we’re just burning these paper towns.