electronic ED charting

[vtucci]

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Hi all.

I was wondering if there is somewhere we can go to find out about which EM Residency programs use electronic ED charting v. hard copy/handwritten T sheets. Before anyone jumps on me, I did look on saem.org/rescat but not all the programs discuss this.

Personally, I prefer electronic charting, orders and records. It removes alot of the hassle of trying to read other people's handwriting. I also type alot faster than I write and can add more details than the small T sheets.

I have also heard people mention that electronic charting in the ED demonstrates a hospital's commitment to the department but I am curious what y'all think about that.

 

[domer621]

I totally agree with you, and prefer everything being electronic. It's so much more efficient, although there are still people out there that prefer paper. I haven't been able to find any info on this besides what the programs list on their webpages and some of the reviews on this forum.

 

[southerndoc]

It's so much more efficient, although there are still people out there that prefer paper. I haven't been able to find any info on this besides what the programs list on their webpages and some of the reviews on this forum.

This is not my experience. Computer physician order entry will slow down a physician. It slows me down at a hospital where I work part-time, and the community hospital where I did residency had this as well. It definitely slowed you down. The part-time hospital where I work now uses the same CPOE system that my main residency hospital used, and it still is slow as all get out.

Most template sheets are quick to complete. Simply check or circle "WNL"/"Normal" and backslash over any pertinent negatives. It's pretty simple.

Be careful what you ask for. You may set yourself up for more aggravation than it's worth. Most docs in my group feel the same way as I do. CPOE and EMR are great for other providers (nurses, secretaries, etc.), but slow the physician down. FWIW, I type 120 wpm, so it's not an issue of typing proficiency or unfamiliarity with the system.

 

[domer621]

This is not my experience. Computer physician order entry will slow down a physician. It slows me down at a hospital where I work part-time, and the community hospital where I did residency had this as well. It definitely slowed you down.

How does it slow you down, southern? The ED electronic software that I've seen is so convenient... all you do is click on things and you can use a bunch of macros that you make. I also like how it has all the dosing of drugs on there, etc.

You're def not the only attending I've heard say that they prefer the paper stuff, though.

 

[kungfufishing]

I think this depends on the system and how fast you type. I went from a computer system in residency to a paper (with electronic d/c stuff) system and found, to my own surprise, that I'm faster on the electronic system. Caveat to this is that I type really fast, but I can do a good electronic note in about one minute.

 

[bookite]

We have computers in almost every room so you can type while you talk to the patient. Much faster. The computer system allows for better documentation as you can free text as well as check boxes.

 

[vtucci]

It may also be the system that you are most familiar with. My home EM program has all electronic charting with computers in each patient room. I love the set up. When I used T sheets at an away rotation, I felt much more limited in what I could say and the scope of my H&P but I probably like to document more than most with my legal background. 🙄

 

[GeneralVeers]

I also support electronic ER charting. I've found that it's mainly the old-timers who two-finger type at 10 wpm that are afraid of the change.

 

[southerndoc]

I think this depends on the system and how fast you type. I went from a computer system in residency to a paper (with electronic d/c stuff) system and found, to my own surprise, that I'm faster on the electronic system. Caveat to this is that I type really fast, but I can do a good electronic note in about one minute.

As I said before, I type 120 wpm. It's easier for me to make one check mark for "CBC" instead of logging into the computer, opening up the patient's order set, clicking on the protocol order set (chest pain, abdominal pain, etc.), and then double clicking the CBC. There really isn't any typing involved. By the time I can open up the program (maybe it's because the computer is slow), I could have already done a complete order set on paper. Our paper order sets at my main hospital are pretty good. Just a check box is all it takes for most labs, ultrasounds, x-rays, etc. Even pain med protocols are there.

We have computers in almost every room so you can type while you talk to the patient. Much faster. The computer system allows for better documentation as you can free text as well as check boxes.

Yea, do this in the community setting and it'll do wonders for your Press-Ganey scores. One of the questions asked is if the doctor took time to listen to you. My group has found through trial and error (a non-scientific study if you will) that when docs type and talk, they get dinged on the Press-Ganey scores. This is why it's discouraged from doing this.

 

[spyderdoc]

We use Ibex (Picis/Pulsecheck). I think it is OK, but it sure does take me a lot longer (in general) to do the electronic chart than paper. For simple things, like URI, kidney stones, etc, the computer chart is better because I use macros to fill in the chart. On more complicated patients, I can spend 10 min doing a chart, esp if I can't use a macro on it.

Computer charting is much better for capturing charges for both the ED/facility as well as for the doctor when you document your procedures. Our revenue went up dramatically after we went computerized charting...

I like CPOE...Kinda cuts out the middle man. Don't need to hand write the order, wait for slow clerk to finish their break, talking on phone, and doing all her other chores, then entering in your orders...Then the orders get to the RN...On CPOE, a red dot shows up immediately on the RNs computer that there are orders to be done...I think it may take more doctor time to do CPOE, but it is more efficient for overall patient throughput.

 

[EM2BE]

Yea, do this in the community setting and it'll do wonders for your Press-Ganey scores. One of the questions asked is if the doctor took time to listen to you. My group has found through trial and error (a non-scientific study if you will) that when docs type and talk, they get dinged on the Press-Ganey scores. This is why it's discouraged from doing this.

I can understand this. I had a physician a while back that was the 2-finger typer at best. I don't think he looked at me the entire time I was there. In the ED, we only have a little time to get to know the patient, and if no eye contact happens, the trust will decrease significantly.

I have another question - If you do the non-computerized method, does every hospital system have you dictate in the end? I think the time to dictate would take up some of the time you would use in the middle of seeing the patient and even out in the end.

 

[kungfufishing]

No, ours is a paper template that we hand write the history and fill in the physical, no dictating. I have no experience with physician order entry but it sounds like a mixed bag of worms (varicocele?).

The computer system in residency had been in place for years and was well tailored to the ED there - quite a bit of work had been put in to making the templates etc. optimal, so all you had to do was type a little, click a bunch, paste some labs, pick your diagnoses, and sign it. I can definitely see where using a system that is not so optimized could be a PITA.

I just finished a shift and spent a lot of time thinking about how much time technology costs us - waiting for the xray program to reload, waiting for the labs to come up, etc. I really enjoyed the hospitals I rotated through as a student and moonlit in as a resident that had paper charts and a lab setup where lab results automatically printed to a printer in the ED - much more freedom than being harnessed to a computer.

 

[docB]

I've been directly involved with putting two EMRs into use now. We first tried the IBEX/Picis system a few years ago and it failed. That was miserable. Now we're looking at a new system and we're not sure which it will be yet.

EMR does slow groups down but there are upsides on quality of records and billing. Now one should get into an EMR believing the crap the salesmen tell you about huge gains across the board immediately. In my experience you're doing pretty good with an EMR if it doesn't kill you and if you're coming out ahead in 12 to 24 months you're ahead of the curve.

 

[spyderdoc]

I've been directly involved with putting two EMRs into use now. We first tried the IBEX/Picis system a few years ago and it failed. That was miserable. Now we're looking at a new system and we're not sure which it will be yet.

I agree. Ibex is fair at best. Since I am the group administrator, I tinker with it a lot to make order sets and put in meds, doses, and routes into the order sets so we don't have to write them all the time. I think I have over a hundred macros, which does help with the more common complaints....I have improved it a lot int eh areas that I have access to tinker with, but there is a lot of work that needs to be done on the templates by Picis.

Unfortunately, our parent company contracts with Picis for all the hospitals, so we are stuck with it.

 

[Aloha Kid]

We use Computer T system. Really nice and convenient. Pretty fast too. Lots of added things in our new version coming up TIMI, WELLS, PORT, etc. Maximizes billing. Shows decision making which can increases billing level. Has many optional things to minimize legal risk. Allows for type in detailed entry. Down side is the cost of the whole system. Probably a million/year.

For order entry we use CAPOE. Lots of different ordersets, but once you get quick enough with it, it's helpful.

 

[AggieSean]

When I was a scribe we used Epic in the ED. The physicians hated it and it was very cumbersome. I have yet to meet anyone that really liked it.

 

[vtucci]

We have been using Wellsoft at Tampa General. I really like it but as a student, we are not able to put in orders so maybe we did not see the downside. However, it was great having the labs pop up (and color coded so if it was urgent labs- red, normal values were green).

 

[dchristismi]

We went live with Picis/Pulsecheck about 2 months ago, and it is definitely slower. There is a learning curve for sure. (I just learned about these mystical macros, which was completely left out of the course we all had to sit through.) I'm going to make a ROS macro first thing this evening at work because it DRIVES ME NUTS!

CPOE isn't bad, just annoying. I do think it's faster in the long run, but getting used to it is tricky. I tend to use the same template for my orders as I know where everything is, rather than the special "chest pain" or "abdominal pain" order sets. Maybe as we settle in I'll keep exploring.

 

[Jeff698]

I did my residency at Scott & White in Temple, Texas. We used IBEX/PICIS. Initially, I hated it but then it grew on me. I forced myself to learn it fully and found I was pretty fast with it.

I now use MedHost and am in the "growing on me" phase. It takes a couple of months to get used to a system before you're optimally proficient with it.

I think the main problem with EMRs is that they dramatically change workflow in a department in unintended ways. Everyone thinks about the physical interaction with the program but forgets about the time it takes to open the program, log-in, etc. We overlook the physical prompt of the chart. In most departments that use paper charts, the chart also serves as a tracking mechanism for the patient. This may or may not be good but your flow will suffer if you get rid of it without considering this as well.

Take care,
Jeff

 

[domer621]

When I was a scribe we used Epic in the ED. The physicians hated it and it was very cumbersome. I have yet to meet anyone that really liked it.

Off-topic, but your avatar is hilarious!

 

[AggieSean]

Off-topic, but your avatar is hilarious!

Thanks, comrade! 😉

 

[physbillercoder]

I work for an EMR company and ours has the charting. A few of our offices have computers in each room but the majority of them prefer the pc tablets. Those are awesome. It's like walking around with a chart only it's a computer! They are light weight and you keep it with you all day. You can also lift up the screen and swivel it around so you can sit at your desk and type.

Oh by the way

 

[TexasTriathlete]

Most docs I've talked to hate electronic charting. Not sure if that's just because its new, and not what they're used to, or maybe they're just using a ****ty program, and the problem could be fixed with a better one?

 

[deleted77919]

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[igcgnerd]

Former Ed scribe here:
We use IBEX at my institution. It isn't ideal but the docs do agree that is a lot easier than paper charting. Mostly because its easier to pull up old records. All labs and CT's/ultrasounds/MRI's cross over all into the same program. It also make it easier so you don't have to decipher a colleague's notes. This system also allows the scribes where I am to do so much. It has gotten to the point where all the doctor needs to do is do the physical exam, put in med orders, and tell us what the final Dx is. The scribes are responsible for the whole chart, putting in orders, tracking everything in the ED. doc's just review the chart, we change it as necessary, and then they sign it.
Due to how thorough you can be with this program the compensation increase is drastic when compared with the old paper charting system. The only way possible sometime to get the level of conversation needed, with all the changing rules for documentation/ billing, is electronically otherwise you would be writing a novel on every patient.

 

[docB]

Former Ed scribe here:
We use IBEX at my institution. It isn't ideal but the docs do agree that is a lot easier than paper charting. Mostly because its easier to pull up old records. All labs and CT's/ultrasounds/MRI's cross over all into the same program. It also make it easier so you don't have to decipher a colleague's notes. This system also allows the scribes where I am to do so much. It has gotten to the point where all the doctor needs to do is do the physical exam, put in med orders, and tell us what the final Dx is. The scribes are responsible for the whole chart, putting in orders, tracking everything in the ED. doc's just review the chart, we change it as necessary, and then they sign it.
Due to how thorough you can be with this program the compensation increase is drastic when compared with the old paper charting system. The only way possible sometime to get the level of conversation needed, with all the changing rules for documentation/ billing, is electronically otherwise you would be writing a novel on every patient.

This is an interesting point. Many EM gorups are dealing with the mandate to adopt electronic charting by hiring scribes. I would argue that this speaks to the problems of an EMR in that it has essentially prove to be unusable by the docs and a whole seperate group of workers had to be hired to fill the gap.

Scribes are expensive (even if they're not paid much per hour). And that expense grows if you try to hire quality people and retain them. If you try to go cheap and pay minimum wage the quality is so low and the turnover so high that you start to lose the coding and charge capture benefits due to incompetence.

My group which is going to adopt an EMR in about 12 months has looked at the scribe issue in detail. We figure we'll need to increase our pt/hr by ~1.5 to 2 or 40 to 60% depending on the doc just to break even on scribes.

 

[Jeff698]

I would argue that this speaks to the problems of an EMR in that it has essentially prove to be unusable by the docs and a whole seperate group of workers had to be hired to fill the gap.

Wouldn't that be a first in health care? Having to hire lost of people who don't contribute to actual health care just to meet arbitrarily imposed requirements.

Scribes are expensive (even if they're not paid much per hour). And that expense grows if you try to hire quality people and retain them.

Each place I've heard of that has a successful program is around a college town. They hire premeds. This gets highly motivated, intelligent people who want to be there. They're willing to work for less money because they're getting more out of it than just the pay.

Take care,
Jeff

BTW, I used iBex in residency and grew to really like it. I use MedHost now and really miss the macro features of iBex.

 

[deleted65604]

I did paper charting in residency, and then switched over mid-way to computer. I now do paper charting and I much prefer it.

Some problems with computer charting-

1. Those computer charts tend to generate very unreadable documents with largely irrelevant information. (My experience from Wellsoft and McKessen) Mckessen is absolutely terrible from that standpoint.

2. It is easy to enter blatantly wrong information on the chart. On Wellsoft, there are numerous default complaint sheets that you pull up and then modify as you go along. The pediatric illness template has a normal gait default, so you rush through the thing, clicking and typing like mad and end up documenting a "normal gait" on a ten month old baby (that can't look good in court). The review of systems checklist tends to be ginormous and, chances are, in real life, you wouldn't ask that many specific yes or no questions. I inadvertently ended up documenting negative answers to questions that I never asked.

3. It can tend to de-personalize the patient encounter. The whole time, you are clicking and modifying and logging on to the computer. In residency, there was a terminal in each room that you could log on. I would end up sometimes with my back to the patient, typing as I talked. If you have a COW, it tends to come between you and the patient. I much prefer a clip-board resting on my knee. I guess you could get a wireless pad, but those things can't be very durable and have to be extremely expensive. (50 cent clip-board that can fall on floor and get barfed on numerous times- maximum out of pocket- 50- cent versus thousands of dollars for wireless tablet that can be wrecked by one fall from the gurney.)

4. The good systems are expensive. We've discussed going to computer charting at my current job. At large institutions, the cost for the T-system is in the hundreds of thousands of dollars range. Would you rather get a big fat bonus for christmas, or have computerized charting?

5. Computer systems crash. We had it happen several times in residency, and it was pain incarnate. All the sudden, you have no idea who needs to be seen and no way to chart on them. Lab interface would break down and we'd have to have lab start tubing down paper copies of labs. The lab techs end up spending half their day answering phone calls from impatient doctors, nurses and ER techs (who are getting yelled at by nurses and doctors to make lab do their job), exacerbating the juggernaut. When computers work good, they are awesome. When they don't, the department grinds to a halt.

 

[xaelia]

I have a little bit of background on this because before I went to medical school I was in CS at Stanford, and worked for Microsoft for a bit, as well as an Information Designer for a SF design firm - and EMR makes me depressed. Medical computing is a decade behind consumer computing, and I still haven't seen anyone making anything worth a damn. I've also been a resident in the land of all paper charting (LA County), and the land of all computer charting (PCMH).

- The physical media required for on-the-fly charting to be as simple as jotting notes on a T-sheet does not exist. When the pinnacle of mass-produced lightweight portable computing is the Kindle, you can see that similar durable, lightweight devices with good screen quality are >5 years away. Tablet computers are not the answer as folks are currently implementing them - or else they would be.

- The user interfaces for all these medical systems are abysmal. We have a custom install of EPIC at our institution, and our ED specific interface has a menu bar at the top, a row of function icons below that, a row of tabs below that, then a left-hand menu (whose options don't fit on screen, so there are scroll buttons), another horizontal row of function icons, a second nested left-hand menu, and then the main content area - which has all sorts of exclusive mode-setting functions within it that lock you in or destroy your work if you try to navigate at the same time.

And this is a $60 million custom build of EPIC, one of the top EMR vendors.

I can't imagine ever getting up past 3 patients an hour on a system like this without simply leaving all my charting to the end. Even with my macros and a bunch of saved dot-phrases, it simply takes 10 minutes per patient to fight through the chart and document everything. The amount of helpful contextual medical information available while writing is nearly zero. Anyone who works for these companies should be stripped of their UI credentials.

Paper charting at LA County was quick and easy - and generated a bulletproof, unreadable, easily misplaced medical record!

EMR obviously has extraordinary advantages in terms of integrating all your information into a readable patient record, the ability to quickly look up past charts, labs, etc. - but thank goodness each hospital will have their own unique system that doesn't talk to each other, so we'll still get 100 pages or more of nursing notes faxed over in the middle of the night.

I have a lot of EMR UI rage; it's one of my dreams to burn existing EMR to the ground and design something doctors would actually feel more efficient using.

 

[Jeff698]

I have a lot of EMR UI rage; it's one of my dreams to burn existing EMR to the ground and design something doctors would actually feel more efficient using.

Thanks for a great summary of the current state of EMRs. I've used to of the better systems (ibex and MedHost) and find both lacking from an efficiency/readability standpoint. There are some very nice features but they're a pain.

My dream system would be an accurate, on-the-fly voice dictation system that pops up on a PDA. We would be able to walk out of the patient's room, dictate the cc, HPI, PMH, ROS, PE and save it. When everything is back and we're ready to make a disposition, click on the patient's name and finish the dictation. We would be able to pull up the initial dictation at any time to remind ourselves what we'd said already. It would then synch wirelessly to the server when you sign it and become part of the overal EMR.

This would give us a quick, intuitive system that works in a way we do. It would relay information to other health care providers. It probably wouldn't bill as well as templates but, with practice, that is solveable.

So, Xaelia, when can I expect to start using this?

BTW, it should run instantaneously on my iPhone. And be able to allow me to do order entry and review of labs. Anywhere in the ED. Anytime.

See, I don't ask much. 🙂

Take care,
Jeff

 

[xaelia]

We would be able to walk out of the patient's room, dictate the cc, HPI, PMH, ROS, PE and save it. When everything is back and we're ready to make a disposition, click on the patient's name and finish the dictation....

See, I don't ask much. 🙂

Why settle? The system should be able to recognize and pick out individual voices in the room, and should automatically record the answers to the questions you ask to an HPI template, as well as the ROS checklist. Any physical exam findings you call out will be automatically added to their exam. It will also pick out any studies or labs you mentioned to the patient and place them in your pending orders to sign.

It will also have a built-in espresso machine.

 

[DeLaughterDO]

Why settle? The system should be able to recognize and pick out individual voices in the room, and should automatically record the answers to the questions you ask to an HPI template, as well as the ROS checklist. Any physical exam findings you call out will be automatically added to their exam. It will also pick out any studies or labs you mentioned to the patient and place them in your pending orders to sign.

It will also have a built-in espresso machine.

I would use this system

 

[GeneralVeers]

There's an app for that......

 

[Apollyon]

One constant of EMRs in the ED is that they were first generated by EPs that were interested, but were not innate computer programmers. When the program became popular enough to go wider, that's when programmers are brought in, and, for better or worse (Ibex, for worse), they have to "unring the bell" and try to make a sturdy house on a weak foundation.

 

[deleted65604]

How does it slow you down, southern? The ED electronic software that I've seen is so convenient... all you do is click on things and you can use a bunch of macros that you make. I also like how it has all the dosing of drugs on there, etc.

You're def not the only attending I've heard say that they prefer the paper stuff, though.

In the Supplement to Annals of Emergency Medicine, October 2008, Volume 52 NO.4, abstract 44 on page S55-

Transitioning from paper to electronic documentation in an urban emergency department: effect on provider efficiency-

Percent of time spent on documentation increased from 22.5% to 29%. That is significant, and it was the same on day one as it was a month later when people should have been used to the charting.

I think these numbers are true just based on my personal experience, plus, if it is published, it must be true, right?

 

[Jeff698]

I think these numbers are true just based on my personal experience, plus, if it is published, it must be true, right?

Especially if it agrees with what I already believe! 🙂

Take care,
Jeff