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Military medicine reform

Discussion in 'Military Medicine' started by IgD, Nov 29, 2008.

  1. IgD

    IgD The Lorax
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    What issues do we need to include on a platform for military medicine reform?

    Here is what I have:
    1. Straight through training and discontinuation of GMO tours
    2. Bonuses paid by the month instead of annually (no raise just simplified pay system)
    3. 360 degree evaluation for promotion: 1) traditional political/subjective evaluation 2) patient evaluation 3) peer/subordinate evaluation
    4. Better respect for professional boundaries. Professional standing trumps rank.
    5. Replacement of AHLTA with VISTA with one system for both DoD and VA
     
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  2. AF_PedsBoy

    AF_PedsBoy Stuffed Animal Overlord
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    How about actually coming through on the frigging manning, and if they can't come through with it adjusting the business plan. Right now the whole reason we're doing ridiculously short appointments is to keep up with the stupid RVU plan and access of care set with 100% manning in mind, while starting 80% manned with one person just set to deploy for the second year in a row, one going TDY on an assigned mission, and about 3-4 people set to PCS out this coming summer. Yeah THAT'S going to work, and when it doesn't our command gets slammed, which passes down to us... Half the clinics got dinged for decreased RVU production during the month we had a week long readiness exercise when everyone was down to one doctor or just plain closed.
     
  3. AF M4

    AF M4 Junior Member
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    Sounds familiar. Don't stress yourself out too much though. Every time you feel the stress coming on, remember two things:

    1) If you protect your patients and your medical license at all times, everything that happens during your GMO years will be water under the bridge in a few years.

    2) No matter how many times random people with too much spare time complain about RVUs or whatever else, so long as you follow #1 and don't commit a felony, what exactly are they going to do? Fire you?
     
  4. OP
    OP
    IgD

    IgD The Lorax
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    That's the idea. What do you think we need to change in the military medical system to improve recruiting/retention? What are some reasonable issues that are actionable?
     
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  5. mitchconnie

    mitchconnie Member
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    I would add:

    Utilization of surgical specialists in a practice setting which allows them to retain their skills.

    i.e. no more surgeons stationed at low-volume clinics where there are minimal inpatient services and nothing to do but C-scopes.

    There are isolated instances where active-duty CT surgeons have been stationed at VA hospitals, a location which allows them to be busy and productive. This sort of creative staffing needs to be the norm, not the exception.
     
  6. mitchconnie

    mitchconnie Member
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    Major reallignment of GME to consolidate at the few remaining large medical centers with closure of most low-volume surgical programs and locations where residents get the majority of their experience at outside institutions.

    Many current active-duty residency spots could easily be replaced with either deferred or civilian-sponsored training. This would be hugely popular with medical students, many of whom pursue civilian deferment like the holy grail.

    I just don't meet a lot of folks (other than prior service) who strongly desire training within the military, but I do meet a lot of people who would much prefer civilian GME and see the prospect of getting forced into a military program as a huge negative. I see zero benefit to propping up unpopular, marginal quality programs when there are high-volume, well-respected civilian institutions that would LOVE to have our American grads.
     
  7. J-Rad

    Physician Moderator Emeritus Verified Expert 15+ Year Member

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    Agree with above, but wonder if this applies most specifically to the USAF GME system, Keesler being the brightest and shiniest example of a "med center" (that isn't) that shouldn't have the GME that it has (or wants).

    I realize that this is a fanciful notion, but I wonder if the (relatively) recently proposed "unified medical command" actually didn't go far enough. Would extracting and unifying all the med corps into a separate service with its own command structure be ideal (functioning in a model like the USPHS provides some medical care to the USCG). It could remove some of the military vs. medical conflicts (on a micro and macro scale) and starting over with an entirely new system might provide the opportunity to create a more efficient "system". I don't think it will happen, but it's interesting to ponder.
     
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  8. AF_PedsBoy

    AF_PedsBoy Stuffed Animal Overlord
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    You know, I think "I Have Altered the Deal" is much better than Dr. Ball...
     
  9. DrMetal

    DrMetal To shred or not shred?
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    Some questions/concerns . . .

    Sounds like this isn't going to happen, entirely. The number of GMO tours may get reduced (especially the # of "unsupervised" ones), but they're probably not going away completely. GMOs are a unique facet of milmed, and if people have great heartache about them, then they probably shouldn't join. Hopefully the quality and professional experiences of the GMO jobs will increase (cool things like humanitarian missions, real wartime trauma experiences, etc etc).

    sounds reasonable enough. also, i'd advocate a significant increase in bonus's and specialty pays, to help bring milmed salaries more on par with the civi world.

    There are parts of the Navy (at least) that have implemented these '360' evaluations. However, the senior rater is still your boss, and he/she still signs the bottom line and has the ultimate authority over the content of your fitrep/eval. The problem with the 360 approach is that it is difficult to standardize the evals and of course there's a ton of subjectiveness that goes into it.

    Just outta curiosity, in the civi world, how are medical professionals 'evaluated' and promoted, say within a hospital ranking structure?

    I think here you're talking about the complaint of having nurses and MSC's acting as your boss, or dictating policy that affects patient care, right?

    I don't think you have a problem with a nurse or MSC telling you what to do, you have a problem with an incompetent nurse or MSC telling you what to do, and telling you to do something that you know is not right nor professional, correct?

    Again, i'll ask for a comparison with the civi world. You have plenty of situs out there where MPHs, nurses, MBAs, JDs even are calling some important shots that affect patient healthcare. So how do civi physicians deal with an MBA telling him/her what to do, or making policy that affects how the MD treats a patient?

    i don't know anything about either system, sounds like each system is very huge and complicated. I'm not sure merging them would be such a great idea. Maybe all that needs to created is a strong line of communication between the two systems, so you can toggle from one database to the other with no loss of data.
     
  10. Perrotfish

    Perrotfish Has an MD in Horribleness
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    .

    Isn't this the basic premise of a standing military? That you have a lot of guys standing around doing nothing except waiting and training to be deployed? Not saying that they'll ever actually overstaff physicians during peacetime, but I don't really see how limiting the number of physicians to peacetime levels is significantly different from limiting the number of Marines to however many we need to guard the embassies.
     
  11. OP
    OP
    IgD

    IgD The Lorax
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    From your posts I got the impression you are prior Navy. What would you think if a supply officer took command of a ship? Wouldn't that be the same as a MSC or nurse taking command of a hospital?
     
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  12. mitchconnie

    mitchconnie Member
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    Tired is 100% correct with his ennumeration of the reasons why things won't change.

    I interpreted this thread as asking the question "What would you like to have in a perfect milmed world?" not "What is actually likely to be accomplished?"
     
  13. DrMetal

    DrMetal To shred or not shred?
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    Yes, prior Navy. I understand your concern. A suppO has no business taking command of a ship (unless all other officers are killed), b/c he has never had the necessary training. so the analogy doesn't quite work. I could see the CHENG taking control of the ship, if say both the CO/XO were KIA. This happened plenty during WWII.

    I'm also thinking about how medicine is run in the civi world. Again, there are MPHs/MBAs that have a considerable amount of admin experience in the civi world. Some of them make decisions that affect how MDs practice. So what about that? My point is that the Navy is not the only place where non-MD call important shots.

    Now, if you were the CO of a hospital, and you had a admin (say dept head) job to fill, and you had two candidates---one an MSC or NC officer, with an MPH in Health Care admin, a proven track record of running clinics and doing what's right for pt healthcare--and the other candidate an introverted MD that's never had admin experience . . . who would you chose? [Perhaps this is too black/white, making the choice obvious.]

    Anyway, from what I gather, the problem occurs when an incompetent MSC/NC officer is placed in charge of better-knowing medical staff . . .from what I gather on this forum, that happens plenty . . .
     
  14. DrMetal

    DrMetal To shred or not shred?
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    you hit the nail right on the head regarding retention . . . if you wanna see what the Navy does when it's really concerned about retention in a particular community, look to the SWO community circa 2001-2003. A lot of JOs were getting out, leaving no one to go to dept. head school. CNO intervened and made policy to offer greater bonuses for going to DH school, and to change the shore/sea rotations. A lot of other little changes took place in the SWO community, that made it more 'attractive'. . It helped, now they're top heavy in O-4's/O-5s!
     
  15. Mirror Form

    Mirror Form Thyroid Storm
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    Actually, according to exit interviews AHLTA is the #3 top reason why physicians are leaving the military. Number one is deployments and #2 was pay difference. Just because doctors are forced to tolerate AHLTA while they're active duty doesn't mean they aren't extremely disgruntled by it. It's definitely a major factor that tips many doctors toward getting out instead of resigning.
     
  16. Gastrapathy

    Gastrapathy no longer apathetic
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    Tired wants to be an orthopod, they simply don't use AHTLA. They dictate notes that no one can see and then code in AHLTA with a couple of sentences that are minimally helpful.

    I try to write meaningful consults and f/u notes and from the list above, I'd rank AHLTA #1.
     
  17. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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    Here's my reasons:

    1) Low level of acuity
    2) Pay
    3) Lack of control over my work environment
    4) Lack of control over the town I live in
    5) Deployments
    6) Military B.S.
    783) AHLTA

    Of course, I can see why AHLTA would be higher if I actually had a password...
     
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  18. Gastrapathy

    Gastrapathy no longer apathetic
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    Really? Its the norm at a certain MTF south of yours.
     
  19. Gastrapathy

    Gastrapathy no longer apathetic
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    I have to admit, this makes me grit my teeth a bit. When I get called from an ER with a consult and the ED doc hasn't even looked at my last note on the patient, its hard not to lose patience. I know AHLTA sucks but it especially sucks when you spend the 15 minutes writing a good note and people don't bother to look at it before waking you up. I think its pretty passive aggressive to play the "gee, I can't take the 5 minutes to look anything up because I just don't have a password." An ED resident tried that on me a couple of weeks ago and when the staff came to the phone and neither of them could look at my note, I told them to get an AHLTA consult and call me back. Unfortunately, they heard "IM consult" and the medicine resident got to read my note, see the scoop and dispo the patient.

    In general, I think emergency physicians have a hard job and do it well. This is a little frustrating, though. AHTLA is crappy but being unwilling to use it is bad for patient care and punishes the rest of us. Oh, and the fact that no ED notes are ever documented anywhere I can find (read: in ALTHA) is frustrating too. Any tips on finding them now that they don't show up in Easy-CHCS?
     
    #19 Gastrapathy, Nov 30, 2008
    Last edited: Nov 30, 2008
  20. Mirror Form

    Mirror Form Thyroid Storm
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    Oh yeah, b/c military medicine is so wonderful that doctors actually couldn't think of anything else to put down as a reason for getting out :rolleyes:
     
  21. Mirror Form

    Mirror Form Thyroid Storm
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    Well yeah, ortho notes are about 3 lines long and typically focus only on one problem. So I can see AHLTA not being a total nightmare in that situation. Unfortunately for me AHLTA is a total Fcking nightmare and pretty much all of my coworkers feel the same way. It's a major reason many military doctors are disgruntled, which contributes to people getting out.
     
  22. Combatbarbie

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    Better respect for professional boundaries. Professional standing trumps rank.

    No way... rank trumps all.
     
  23. OP
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    IgD

    IgD The Lorax
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    You've mentioned this several times in different threads. There are some vague similarities but otherwise the comparison is like apples and oranges. Your point sounds like the sales pitch the military medicine leaders make when they try to convince people to stay in.

    Here is a situation I saw that helps illustrate the point: One day, the hospital commander, a nurse decided to change the on-call procedures for psychiatry. He ignored the advice of the psychiatrists and didn't get any input from nursing or the emergency room who all disagreed with the policy change. He just unilaterally implemented the change. We had absolutely no recourse because the hospital CO had absolute power and made this clear. He ignored feedback from senior military psychiatrists and even our professional association. He also didn't face any real repercussions from this decision. This would have never happened in the civilian world.

    Why don't we have supply officers or chief engineers with a master's degree who become the CO of the ship? We don't because its a professional boundary issue. The outcome of the situation I described is exactly what you would have expected with such a setup.
     
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    #23 IgD, Dec 1, 2008
    Last edited: Dec 1, 2008
  24. sethco

    sethco Senior Member
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    Really surprised nobody has mentioned this yet.

    I am a huge advocate for the addition of Copays to Tricare and basically turning it into a PPO system.

    For the providers not at a major MEDCEN, access to civilian specialists are a big problem. Reimbursements have dropped significantly over the years to the point where the majority of civilian providers refuse to see Tricare patients. I am tired of waiting >3 months for a GI, Neurology, or whatever referral.

    Copays and Deductibles would go a long way to helping (but not solving) this problem.
     
  25. DrMetal

    DrMetal To shred or not shred?
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    Ok, good example. Well then that particular Nurse CO was an idiot b/c he was unable to listen to his subordinates that were actually carrying out the work.

    So, exactly what kind of new policy (do you think) would eliviate these situations? Make a rule that a hosp CO must be an MC billet? (so that a nurse or MSC could never be in charge) Or, even if the job is run by a non-MC, allow the medical staff to make their own rules and policies?

    I ask about the civilian world b/c that's the only other point of reference we have. I'm just curious as to how the civi world handles similar dilemmas and if the military can/should leverage their solutions. If we draw comparisons to civi pay, we can certainly do so with respect to civi policy.
     
  26. notdeadyet

    notdeadyet Still in California
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    I think you might be overestimating how much direct control the suits have over how the individual physician practices his clinical medicine in the civilian world.
     
  27. DrMetal

    DrMetal To shred or not shred?
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    right, which goes back to your original point that things probably aren't going to change . . . there doesn't seem to be a better alternative . . unless we can come up with one here !

    ok, thanks for the input. I've been talking to a handful of civi docs (friends and family) working in large hospitals . . .they have some complaints about their CEO/COO staff, some of which involves healthcare (not being able to orders certain tests, or having to justify really hard why they want to order something, etc etc). But they never feel 'limited', other than a few roadbumps with the suits, they feel pretty content about their jobs . . .
     
  28. sethco

    sethco Senior Member
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    Midwestern City, metro poulation 1.1 million. Major civilian training program nearby. Doesn't stop the majority of civilian providers from not taking Tricare patients.
     
  29. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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    You make good points. Any idea how to get an AHLTA consult? Hopefully it doesn't involve calling the same people I call when my computer won't print, because they don't work the same hours I do. Amazingly, there is no computer support during 3/4 of the shifts I work. (evenings, nights, weekends, and holidays make up 128 of the 168 hours in a week that the ED is open.)

    I always wondered why I was never sent to "AHLTA" training, given a password etc. I mean, there is no doubt you cannot use it effectively to document your own notes in the ED (at least at those times you're seeing 3-8 patients per hour), but it would be nice to be able to look up past ones.

    Our written/templated notes are scanned in to the computer and available to the entire med group on a shared drive. You would need to know date of service and social to find them though. The original ends up in their written chart. Not ideal, but a better solution for us than AHLTA.

    Supposedly, within about a year, there will be an ED-specific EMR that will resolve some of these issues. In the meantime, maybe I should burn some of my time off trying to figure out how to get an AHLTA password....
     
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  30. delicatefade

    delicatefade ASA Member
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    The attendings and residents at WBAMC dictate their AHLTA notes.

    I think it shows what a failure AHLTA has been. One of the reasons they designed AHLTA with its "click boxes" was so that notes could be coded almost automatically without the use of coders, which theoretically would save money by shifting that workload onto physicians who now have to deal with all the click boxes and unreadable notes.

    But who codes the ortho notes at WBAMC??? Coders. They are still paying coders to code AHLTA notes which shouldn't really need coding at all.
     
  31. AF_PedsBoy

    AF_PedsBoy Stuffed Animal Overlord
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    I got tired of clicking boxes and having half page notes balloon into useless 3 page notes no one reads - when I go on AHLTA I read the first history blurb then skip down to the A/P section because everything in between is useless coder crap. For my notes I just free text what I want, and override the coding at the end. Even then I can't escape the extra work having to enter accident codes,or three separate codes for every PAP smear, but at least I'm only taking a few hours at the end of the day doing clinic notes instead of coming in on weekends trying to catch up on the week's notes... our AHLTA guy is really good about wandering by every so often and seeing if we need anything, but I can almost see little clouds of steam over his head sometimes when he sees how I'm using his AHLTA program... :laugh:
     
  32. deuist

    deuist Stealthfully Sarcastic
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    The EM3 program at Lackland is amazing. It works beautifully and fully integrates everything I would need to know about a patient. We never have to call for old charts.
     
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  33. Gastrapathy

    Gastrapathy no longer apathetic
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    That doesn't sound too bad. I know its impossible for ED types to actually use AHLTA (thats a strike against AHLTA rather than the doctors). The fact that we need a different EMR for the ED is pretty telling.

    Tired's advice about saying you've had the training is right-on. The best thing about AHLTA, btw, is that you can see studies from other places. So when you get that medevac from Germany, you can see the prior studies.
     
  34. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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    Believe it or not, it wasn't part of my check-in at any of the four AF/NAVY MTFs I have "checked into." Granted, three of those four were half-assed check-ins, but still....

    AHLTA with templates may work well when the system is up, but based on the number of emails I get about it, it is often down completely on Friday nights when things get really busy for me, and always slow during the duty day. I cannot use an EMR that actually plans to go down once a month for half a shift for updating. WTH am I supposed to do, stay hours late to do notes on patients I can no longer remember? No thanks. The EMR I use at my moonlighting job can amazingly update itself without being turned off. Why can't AHLTA do that? I'll tell you why. Just like the rest of the AF, people assume that just because they work 7:30-4:30 everyone else does too. When they start having mandatory PT and mandatory commander's calls at 0200 on Saturday morning after Thanksgiving I'll believe someone actually understands something about shift work.
     
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  35. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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    Yes, we came very close to adapting that one at one of the facilities I work at. The problem was it is "home-grown" and no one knows how to maintain it except the guys at Big Willie. I'm sure the group looking into the new one will try to incorporate its best parts. My favorite ED specific EMR so far is called PICIS, but I've worked with a lot of crappy ones in the past (none of which were as bad as AHLTA BTW.)
     
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  36. Mirror Form

    Mirror Form Thyroid Storm
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    It's not an option for many subspecialties b/c there are far too many medical words that aren't translated correctly with the available speech to text programs (eg dragonspeak).

    Navy takes ahlta rvu's very seriously, so the guys at NCC are excellent at coding for max rvu's.
     
  37. Mirror Form

    Mirror Form Thyroid Storm
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    Sure, ahlta templates may work well for that 10 percent of patients who actually only have one routine problem. And by "works well" I mean it only takes 10 times longer than a hand written note.

    Anyway, even the military's brass have pretty much given up on defending AHLTA. I don't see why any practicing clinicians would ever defend such a collosal disaster.
     
  38. a1qwerty55

    a1qwerty55 Attending
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    I'm sorry, this isn't accurate at least with the 10.0 Dragon Medical.

    The Army Surgeon General has set aside funds to provide voice recognition software for all providers. Many providers have experience with Dragon Medical and have been impressed with the breadth of the terminology, abbreviations etc (If you find one that isn't there,you can easily train it) and can insert templates - i.e. op note templates, text for consent forms, etc.

    It works very well with AHLTA, and can dramatically improve note quality and efficiency and provider satisfaction. This was presented at a national meeting. The Army has given clearance to manual coding thus averting the need for the stupid Medcin tree blocks and templates.

    I am not aware of the USAF or USN looking to incorporate this technology. So much for the Army guys being a bunch of tech idiots.
     
  39. AF_PedsBoy

    AF_PedsBoy Stuffed Animal Overlord
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    What? We need clearance for manual coding?
    ...uh oh :laugh:
     
  40. OP
    OP
    IgD

    IgD The Lorax
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    Seems kind of short sighted to throw a bunch of money to put a band-aid over an open wound. Wouldn't it be better to correct the underlying problem which is a design flaw in AHLTA?
     
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  41. a1qwerty55

    a1qwerty55 Attending
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    Are you kidding?? - we are like 6 billion into this thing and every fix creates a new problem. A cost of $800/provider is chump change. This fix makes it useable, and fairly user friendly and more efficient. Can you imagine trying to get the contractor to fix anything of significance for such a paltry sum?

    The push for this actually came from a Navy Neurologist in Pensacola (I'll give credit where credit is due)- the Army in Europe ran with it however then it went Army wide. AHLTA aint going away any time soon so rather than rail against it, we might as well find a way to use it efficiently so we can leave the hospital/clinic at a reasonable hour.
     
  42. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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    I watched 20 residents try to learn dragon speak. After 4 months the department gave up on it and went to templated charts. If that's the improvement, I'm definitely getting out.
     
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  43. a1qwerty55

    a1qwerty55 Attending
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    I guess my coworkers are gifted, or your 20 residents are....?

    It is all about dedicating a little time (like 2 hours) to learning the commands, and training it. I suspect that the roll out was botched if 20 residents couldn't use it. Also - the key is having a physician teach it, since you don't need 90% of the commands to make it useful
     

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