Electronic Medical Record

[atacs]

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This is directed to all medical students, residents, and attendings in psychiatry. Has your hospital fully implemented the EMR? Specifically, are you required to type (not write or dictate) all admissions, daily notes, and discharge summaries?

 

[whopper]

The hospital I work at the most-partially (Atlantic Regional Medical Center in NJ).

Any note can be dictated & then are transcribed into a program we call Powerchart. Some notes are required to be dictated (discharge summaries, consults), some notes you can dictate but still have the option of writing.

ARMC will though in the near future implement a program called Avatar where some notes (H&Ps & progress notes) will then have to be put in electronic format & the doctors will have to type those notes. I believe other documents will still be allowed for dictation. Avatar has already been implemented in our psychiatry outpatient offices.

I'm not happy with Avatar. A note I could've written up in 3 minutes now takes 15 minutes, and I only have about 20 minutes per patient. Its forced the interviews to be much less personal because I'm typing all the time. You have to type everything from scratch--there is no template, nor are there any options you can click (e.g. they'll give you affect, you click on one of 5 descriptions or type in your own).

I've brought this up to the management. I've reccomended Avatar be altered in a manner that where it has a template & allows us to click onto options with an "other" option where we can type in the description if the options don't fit the patient, instead of having to type the entire note from scratch. (everything-even the words History & Physical & Chief Complaint)

I can only hope they follow my advice. If they don't, by the time this thing rolls into inpatient, it'll turn a 8-3 day into an 8-8 day with everyone wanting to pull their hair out. I'm pretty certain they'll eventually do what I ask, but hopefully before we go through a heck period where everyone's miserable and I have to give them an "I told you so".

I'm about 99% confident this will happen smoothly because our inpatient nurse manager is very savvy & can tell this will be a problem. However, our outpatient offices still have the doctors writing the complete note from scratch.

 

[Hurricane]

Only at the VA. The other hospitals in our system are in various stages of transition to EMR. This can't happen soon enough. If I could have back all the time I spend hunting for charts and various missing pieces of charts, I bet I could have an extra week of vacation a year.

 

[OldPsychDoc]

We are fully implemented with something called EPIC--clearly designed by programmers and administrators, not clinicians. It's a mixed bag--I'm not one of the old guard Luddites (of which we have a few on staff), but it can be frustrating, even for the computer literate. I refuse to type notes and interact with the computer whle I'm interviewing the patient (unless I'm going over a med list or something with them), so I end up typing in a note afterward from my scribbled jottings--unless I was luck enough to have a med student "acting as scribe"😀. It can add extra time at the end of the day, but I'm learning shortcuts and efficiencies. Still, no administrative meeting goes by without someone complaining about how some piece of the software is threatening patient safety somehow...

Attendings still dictate some admissions, consults and d/c summaries. Legibility is of course improved--but it seems that the note templates reward the inclusion of pages of meaningless information as opposed to meaningful integration and synthesis of key data. It can still be very hard to find relevant info in the blizzard of database entries from every ED tech who brought the patient a glass of water...

 

[whopper]

I'm not one of the old guard Luddites (of which we have a few on staff), but it can be frustrating, even for the computer literate. I refuse to type notes and interact with the computer whle I'm interviewing the patient

Same problem going on here. I thought electronic notes would make things more efficient. They haven't. Its very annoying for the patient to see you type & not look at them during the interview.

I think electronic notes can be done in a manner where they are more efficient than hand written notes, but at this point in time we're not yet acheiving it. As a medstudent, our GI attendings used an electronic program for colonoscopy reporting and it made a very concise, well written note in about 10 minutes that would've taken about 20 minutes to write up. It also included color photos in the report.

 

[Faebinder]

Some EMRs absolutely suck. Alright so your patient that you are admitting has the medical history of hypothyroidism and lets say pseudogout and had temporal craniotomy in 1991. You're gonna have to put this in every admission note anyway inorder for the payment coders to properly code it so why isnt the EMR auto inserting this in every admission note? Things that don't change from admission to admission: PMHx, PSHx, ALLERGIES, Family Hx. They should be auto inserted but editable by the user.

Electronic progress note should have daily labs if any or last lab values and vitals autoinserted into them.

The lack of user friendliness comes from the lack of money support for EMR is in my opinion. I think we all would benefit from a universal EMR system. Too bad the hospitals dont think this way.

 

[whopper]

a universal EMR system

I've wondered this could be a good way to catch those types of patients that go from hospital to hospital when the former one figures out they got something such as malingering or factitious.

I had one patient who comes in about every week after he went on a cocaine binge-after he uses up all his welfare money. He would fake suicidal ideation to get in. We stopped admitting him because he was basically using the hospital as a way to get free food until his next welfare check.

So then I'm visiting a buddy at another hospital one day and cocaine-malinerger man is over at that hospital! He figured out he couldn't use us, so he went over to the next county.

The guy has it down to a science. Once he's worn out his welcome, he just gravitates to one of 3 counties which are easily accessible by bus. Then by the time he's on his 3rd, he'll go back to the 1st, and because they haven't seen the guy in a few months they're willing to take him in again.

If we had a universal record system, we'd be able to catch these people. None of the 3 hospitals talk to each other. I only found this out after about 2 years and occasionally talking to staff & residents from the other places.

 

[Faebinder]

I've wondered this could be a good way to catch those types of patients that go from hospital to hospital one the former one figures out they got something such as malingering or factitious.

I had one patient who comes in about every week after he went on a cocaine binge-until he uses up all his welfare money. He would fake suicidal ideation to get in. We stopped admitted him because he was basically using the hospital as a way to get free food until his next welfare check.

So then I'm visiting a buddy at another hospital one day and cocaine-malinerger man is over at that hospital! He figured out he couldn't use us, so he went over to the next county.

The guy has it down to a science. Once he's worn out his welcome, he just gravitates to one of 3 counties which are easily accessible by bus. Then by the time he's on his 3rd, he'll go back to the 1st, and because they haven't seen the guy in a few months they're willing to take him in again.

If we had a universal record system, we'd be able to catch these people. None of the 3 hospitals talk to each other. I only found this out after about 2 years and occasionally talking to staff & residents from the other places.

I think medicare could save itself a lot of money by implementing a universal EMR. Though it might be the first towards universal healthcare as well. But the problem is of course the different software developers wont join together unless the software is developed by something like the government. It's sorta like Windows and MACs.. We need a giant to take over the EMR business and make it well wide spread. It would be nice for a person to just store all there records on this one flash drive. Ya, ya wishful thinking.

 

[whopper]

Ya, ya wishful thinking.

We had a grand rounds on this same subject, done by a family practice doctor who mentioned his frustration on dealing with recently discharged patients with no discharge summary because docs got 1 month to do the DS.

So he gets a patient 1 week after discharge and he doesn't know why they're on the meds they were prescribed. The patient doesn't either. So he asks the hospital for a DS, and it won't be ready for several days.

I mentioned the flashdrive idea.

His response...

The problem with a flashdrive is the very patients that cause the frustration are the same people that wouldn't carry a flashdrive. The "responsible" patients usually know why they're on their meds & have fairly good insight.

The "other" patients show up to the ER fairly often--and with no idea on what they're on. They just know they need help because they got something like chest pain.

 

[Faebinder]

We had a grand rounds on this same subject, done by a family practice doctor who mentioned his frustration on dealing with recently discharged patients with no discharge summary because docs got 1 month to do the DS.

So he gets a patient 1 week after discharge and he doesn't know why they're on the meds they were prescribed. The patient doesn't either. So he asks the hospital for a DS, and it won't be ready for several days.

I mentioned the flashdrive idea.

His response...

The problem with a flashdrive is the very patients that cause the frustration are the same people that wouldn't carry a flashdrive. The "responsible" patients usually know why they're on their meds & have fairly good insight.

The "other" patients show up to the ER fairly often--and with no idea on what they're on. They just know they need help because they got something like chest pain.

Ahh, the classic "I dont know why I am here" patient.

 

[OldPsychDoc]

Ahh, the classic "I dont know why I am here" patient.

Implantable chips, anyone?

 

[atacs]

Thanks everyone for your replies. Typing is not my forte.

 

[Hurricane]

EPIC sucks. That's what our main hospital and some of the private hospitals are in various stages of implementing. Whoever said it doesn't appear to have been designed by clinicians is absolutely right. More like billing people or HUCs.

The VA system isn't a pretty, but it's the best I've ever seen. It does all the things mentioned above. You can make your own templates that autoinsert labs, vitals, meds, new orders, demographics, upcoming clinic appointments, etc into your notes, histories, dc summaries, etc. You can look at data from other VAs and DOD hospitals to get more info, and I have used this feature to kick out malingerers. You can sort and search notes by author, date, location, etc. If your patient is on an atypical and nobody has checked lipids in a year, it will remind you and tell you to click here to order a lipid panel. The EMR is hands down the best thing about the VA.

 

[whopper]

Anyone here like any EMR's?

The only one I've seen that was good was the one used for colonscopies (mentioned above). Don't know the name of it.

 

[MBK2003]

I've interacted with 3 different EMRs during residency and fellowship, two I liked and one I despised.

In residency the child clinic had a self-designed web-based EMR that was seamless between ER, mobile crisis, home-based services, and outpatient care, including therapists and MD notes. It required a good bit of info to be put in for 1st evals, but effectively carried forward diagnoses into treatment plans, progress notes, and discharge summaries, as well had a copy note feature that was AWESOME. Under 5 min to generate a progress note.

The adult clinic, however, felt that utilizing an EMR based upon the vaunted "Duke" system was the best way to spend $. It took an hour to generate an intake note, each progress note required re-entry of the ENTIRE NOTE and needed you to make multiple point & clicks and opening up new windows to complete the minimum required elements for the note to save so that it took a good 15 min to write a stupid therapy progress note. The best part was that because it was a system generated by another institution, we got none of the requested upgrades or improvements during the first 2 years of use. It was only used in the outpatient unit, so ER notes, mobile crisis notes, and inpatient notes were not available in the same EMR platform.

In my fellowship training we have MEDITECH which includes scheduling, registration, and outpatient clinic notes. Inpatient notes are also available in a click, but the ER is still pen/paper notes. The best feature by far of Meditech is that we have a staff member in the building who is a trainer and upgrader for the software, so when I wanted an alternative progress note template she installed my template into the system within a week. It copies progress notes easily and if I can get a tablet PC I'll be able to do new eval notes within the session (50% check box template).

 

[GBotDO]

Thanks for the Meditech info.

I'll be paying attention to this thread. I'm on clinical rotations now. The doc I'm with found out I'm good with computers, so now I'm his official advisor on EMRs...

So does anyone have an EMR that they LIKE? Preferably one that works well on WinXP Tablet Edition.

Thanks,
G